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Essentials  of 
Operative  Dentistry 


WITH  illustrations 

BY 

W.  CLYDE   DAVIS,  B.  S.,  M.  D..  D.  D.  S. 

Dean  and  Professor  of  Operative  Dentistry  and  Technic,  Lincoln 

Dental    College,  Associated  with  the  University  of 

Nebraska,  Lincoln,  Nebraska. 


PUBLISHED   BY   THE    AUTHOR 
1911 


Entered,  according  to  Act  of  Congress,  in  the  year  1911, 

by  W.  Clyde  Davis,  in  the  Office  of  the  Librarian, 

of    Congress,    at    "Washington,    D.    C. 


Entered  at  Stationers'  Hall, 
London,  England. 


PREFACE. 

In  the  preparation  of  this  text  book  it  has  been  the  author's 
aim  to  meet  a  demand  in  dental  college  work  for  a  treatise 
on  operative  dentistry  which  is  sufficiently  condensed  for  the 
student  to  master  its  contents  in  the  comparatively  short 
college  terms  at  his  disposal,  and  at  a  price  within  the  limita- 
tion of  the  shortest  purse  strings. 

The  subject  matter  selected  is  that  which  is  generally  taught 
by  the  instructors  styled  as  "Professor  of  Operative  Den- 
tistry." 

From  a  study  of  these  teacher's  courses  of  instruction  it 
would  seem  that  the  definition  of  Operative  Dentistry  as  com- 
monly used  today  would  be  "That  branch  of  dentistry  which 
treats  of  the  mechanical  procedures  performed  within  the  oral 
cavity  looking  to  the  salvage  of  the  teeth." 

However,  it  has  seemed  wise  in  several  instances  to  go  be- 
yond the  exact  limitations  of  this  definition  to  get  a  better 
correlation  of  subjects. 

The  arrangement  of  the  subject  matter  is  dififerent  from 
that  usually  found,  but  is  in  accordance  with  the  usual  line 
of  progress  of  dental  students. 

The  author  claims  little  originality  in  the  essentials  pre- 
sented, having  gleaned  the  facts  from  the  writings,  teachings 
and  utterances  of  our  greatest  educators,  a  list  of  Avhom  is 
herein  given. 

The  "quiz-explanation"  method  of  teaching  is  the  one  most 
in  vogue  in  the  leading  universities  as  productive  of  the  most 
work  on  the  part  of  the  classes  taught,  and  at  the  same  time 
giving  the  tutor  more  freedom  for  the  expression  of  opinions 
to  give  inrlividuality  to  his  course  of  instruction. 

An  effort  has  been  made  to  so  publish  the  "Essentials  of 
<)perative  Dentistry"  that  it  would  serve  as  a  foundation  for 
this  quiz  course  as  well  as  be  suggestive  to  the  teacher  for  a 


4  ESSENTIALS  OF  OPERATIVE  DENTISTRY 

more  full  explanation,  and  at  the  same  time  encourage  the 
student  to  extend  his  studies  to  more  voluminous  reference 
books,  when  time  would  permit,  for  an  explanation  in  greater 
detail. 

The  author  is  much  indebted  to  his  co-laborer,  partner  and 
wife,  Mattie  M.  Davis,  D.  M.  D.,  for  valuable  assistance  in 
connection  with  the  publication  of  this  volume.  W.  C.  D. 


The  following  list  is  the  names  of  those  Dental  educators 
whose  instructions,  publications  and  writings  have  been  con- 
sidered : 

Charles  Channing  Allen,  D.  D.  S. 

Henry  h.  Ambier,  M.  S.,  D.  D.  S.,  M.  D. 

Henry  L.  Banzhaf,  B.  S.,  D.  D.  S. 

G.  V.  Black,  M.  D,.  D.  D.  S.,  Sc.  D.,  L.  L.  D. 

I.  Norman  Broomell,  D.  D:  S. 

Andrew  J.  Brown,  D.  D.  S. 

J.  P.  Buckley,  Ph.  G.,  D.  D.  S. 

Henry  H.  Burchard,  M.  D.,  D.  D.  S. 

John  Q.  Bvram,  D.  D.  S. 
■  David  M.  Cattell,  D.  D.  S. 

WilHam  T.  Chambers,  D.  D.  S. 

William  Crenshaw,  D.  D.  S. 

E.  E.  Cruzen,  D.  D.  S. 

William  Harper  DeFord,  A.  M.,  D.  D.  S.,  M.  D. 

Frank  F.  Fletcher,  D.  D.  S. 

Lewis  E.  Ford,  D.  D.  S. 

M.  Whilldin  Foster,  M.  D.,  D.  D.  S. 

Andrew  G.  Friedricks,  M.  D.,  D.  D.  S. 

H.  E.  Friesell,  D.  D.  S. 

Donald  Mackay  Gallic,  D.  D.  S. 

Suneon  H.  Guilford,  A.  M.,  D.  D.  S.,  Ph.  D. 

James  H.  Harris,  M.  D.,  D.  D.  S. 

Thom.as  P.  Hinman,  D.  D.  S. 

Joseph  D.  Hodgen,  D.  D.  S. 

Frank  Holland,  M.  D. 


ESSENTIALS  OF  OPERATIVE  DENTISTRY 

George  Edwin  Hunt,  M.  D.,  D.  D.  S. 

A.  O.  Hunt,  D.  D.  S. 

R.  E.  Hutchenson,  AI.  D.,  Ph.  G.,  D.  D.  S. 

C.  N.  Johnson,  M.  A.,  L.  D.  S.,  D.  D.  S. 
G.  S.  Junkerman,  A.  M.,  M.  D.,  D.  D.  S. 
John  Hanger  Kennerly,  M.  D.,  D.  D.  S. 
Edward  C.  Kirk,  D.  D.  S,  Sc.  D. 
John  Savre  IMarshall,  M.  D. 

D.  J.  McMillen,  M.  D.,  D.  D.  S. 
Herbert  C.  Miller,  M.  D.,  D.  D.  S. 
Thomas  Morffew,  D.  D.  S. 

Alfred  Owre.  D.  M.  D.,  M.  D.  C.  M. 
J.  D.  Patterson,  D.  D.  S. 
Daniel  H.  Sanire,  D.  D.  S. 
Richard  L.  Simpson,  A.  M.,  D.  D.  S. 
J.  B.   Singleton,   D.   D.   S. 

B.  Holly  Smith,  D.  D.  S. 
Arthur  L.  Swift,  D.  D.  S. 
Henry  C.  Thompson,   D.   D.   S. 
Harry  B.  Tileston,  D.  D.  S. 
Eugene  T.  Vincent,  D.  D.  S. 

A.  E.  Webster,  M.  D.,  L.  D.  S  ,  D.  D.  S. 
F.  L.  Whitman,  B.  S.,  D.  D.  S. 


ESSENTIALS  OF  OPERATIVE  DENTISTRY 


CONTENTS 


PART    I. 

CHAPTER  1 17 

REVIEW  OF  TOOTH  NOMENCLATURE;.  The  Human 
Denture. — Occlusion. — Articulation. — The  Temporary  Denture. 
— The  Median  Line. — The  Permanent  Denture. — The  First 
Permanent  Tooth  to  Erupt. — The  Physical  Divisions  of  a 
Tooth. — The  Crown. — The  Root. — The  Neck. — The  Alveolus. 
• — -The  Apex. — The  Apical  Foramen. — Surfaces  of  Incisors  and 
Cuspids. — Surfaces  of  Molars  and  Bicuspids. — An  Axillary  Sur- 
face.— The  proximal  Surface. — Contact  Point. — Division  of  Sur- 
faces.— Two  Kinds  of  Angles. — A  Line  Ang-le. — A  Point  Angle. 
— An  Axial  Line  Angle. — The  Marginal  Ridge. — Naming  of  Line 
Angles  and  Point  Angles. — The  Gingival  Point  Angle. — The 
Angle  of  a  Surface  is  Named. — A  Cusp. — A  Slight  Elevation. — 
Defining  a  Ridge. — A  Triangular  Ridge. — A  Transverse  Ridge. 
— ^A  Fossa. — A  Sulcus. — A  Groove. — A  Sulcate  Groove. — A  Fis- 
sure.— A  Developmental  Groove. — The  Inter- Proximal  Space. — 
The  Inter-Proximal  Embrasures. — Pulp  Chamber. — Pulp  Canals. 
— Horns  of  a  Pulp. 

CHAPTER   II 24 

REVIEW!  OF  DENTAL  HISTOLOGY.  Dental  Histology  De- 
fined.— Teeth  Belong  to  Dermal  Skeleton. — Tissues  Which  Make 
Up  a  Tooth. — Enamel  Is  Derived. — The  Dental  Papilla. — The 
Pulp. — The  Cuticula  Dentis.— Chemical  Composition  of  Enamel. 
Structure  of  Ebamel. — The  Enamel  Rods. — Composition  of 
Enamel  Rods. — Length  of  Enamel  Rods. — Curvature  of  Enamel 
Rods. — Diameter  of  Enamel  Rods. — The  Interprismatic  Ce- 
ment.— The  Cleavage  of  Enamel. — The  Dentine  Histologically. 
Physical  Structure  of  Dentine. — The  Matrix. — Chemical  Compo- 
sition of  Dentine. — Principal  Inorganic  Substances. — The  Den- 
tinal Tubules. — Contents  of  Tubiiles. — Medium  of  Sensation. 
— Length  of  Tubules. — The  Odontoblasts. — Primary  Dentine. — 
Secondary  Dentine. — Cementum. — Hypercementosis. — Cemento- 
blasts. — Tooth's  Pulp. — Tissues  of  the  Pulp. — The  Shape  of  the 
Pulp. — Line  of  Retraction  of  the  Pulp. — The  Pericementum. 
— The  Functions  of  the  Pericementum.^ — Arrangement  of  the 
Fibers. — Tooth's  Tactile  Sense. — Tooth's  Nutriment. — The  Cel- 
lular Elements  of  the  Pericem.entum  Cementoblasts. — Fibro- 
blasts.— Osteoblasts. — Osteoclasts. — Eipithelial  Bodies. 

CHAPTER   in 82 

INSTRUMEINT  NOMENCLATURE.  Defining  Dental  Instru- 
ment.— Plan  of  Naming. — Order  NIame. — Sub -order  Name. — 
Class  Name. — Sub-class  Name. — Rights  and  Lefts. — An  Exca- 
vator.—A  Chisel. — A  Chisel  Edge. — Use  of  the  Chisel.— Divi- 
sion of  Chisels. — A  Hoe. — Division  of  Hoes. — A  Hatchet. — Divi- 
sion of  Hatchets. — Gingival  Marginal  Trimmer. — A  Spoon. — Use 
of  Spoon. — Angles  Designated. — The  Contra-angle. — When  Bin- 
angles  and  Triple  Angles  Should  Be  Contra-angled. — A  Form- 


CONTENTS 


ula  Name. — A  Plugger. — The  Dental  Engine. — The  Engine  Bur. 
— Indispensable  Uses  of  Engine. — Sharpening  of  Instruments. — 
As  Instruments  Are  Shipped. — Test  for  Sharpness. 


PART    II. 

CHAPTEK    IV -36 

CAVITY  NOMENCLATURE.  Why  Necessary. — How  Named. 
— Proximal  Cavities.  A  Simple  Cavity.— A  Complex  Cavity. — 
Complex  Cavities  Named. — An  Axial  Surface  Cavity. — Division 
of  Cavities  as  to  Origin.— Pit  and  Fissure  Cavities.— Smooth 
Surface  Cavities.— Grouping  of  Cavities  as  to  Dine  of  Treat- 
ment.—Class  I.— Class  II.— Class  III.— Class  IV.— Class  V.— 
Class  VI.— Naming  Outside  Walls  of  Cavity.— Pulpal  Wall.— 
Sub-pulpal  Wall.— Axial  Wall.— In  Case  Pulp  Is  Removed.— 
Gingival  Wall.— Both  Gingival  and  Sub-pulpal  Wall  Present.— 
Outside  Wall  Defined. — Inside  Wall  Defined. — Base  of  Cavity 
Defined.— Line  Angle  Is  Defined  and  Named.— One  Exception. 
—Point  Angle  Is  Defined  and  Named.— One  Exception.— Inter- 
nal Line  Angles.— External  JUine  Angles.— Enamel  Margin  De- 
fined.—External  Enamel  Line.— Cavo-surface  Angle.— Base  of 
the  ravo-surface  Angle.— The  INIarginal  Bevel.— Necessity  for 
Beveling.— The  Bevel  Angle.— The  Base  of  the  Bevel  Angle.— 
Distance  of  Bevel  Angle  From  Enamel  Margin.— The  Planes 
of  a  Tooth.— Horizontal  Plane.— Mesio-Distal  Plane.— Bucco- 
Lingual   Plane. 

CHAPTER    V ^^ 

CAVITY  PREPARATION.  GENERAL  CONSIDERATIONS. 
Cavity  Preparation  Defined.— The  Completed  Cavity  Should  Be. 
—Division  of  Cavities  as  to  Origin.— Pit  and  Fissure  Cavities.— 
Location.— Smooth  Surface  Cavities  Defined.— Predisposing 
Cause.— Naming  and  Defining  Cavities  as  to  Similarity  in 
Method  of  Management.— Necessity  for  Modification  in  Form. 
—Selection  of  Filling  Materials.— Necessity  for  Order  of  Pro- 
cedure.— Extension  for  Prevention  Defined. — Affected  Dentine 
Defined.— Infected   Dentine  Defined.- Objects  in   Filling  Teeth. 

CHAPTER    VI ^^ 

GAINING  ACCESS  IN  CAVITY  PREPARATION.  Defined. 
—Importance  of  Sufficient  Access.- Access  to  the  Tooth.— Ac- 
cess to  the  Cavity.— Surgical  Access. — Access  as  Related  to  the 
Restoration  of  Proximal  Space.— Effect  of  a  Disregard  of  This 
Fact.— Preliminary  Separation.— Proper  Contact  Point.— The 
Saving  of  Tooth  Substance.— Methods  of  Separation.— Best 
Means  of  Preliminary  Separation.— Class  II.— Also  Class  III. — 
Avoiding  Gum  Injury.— Immediate  Separation.— Management 
of    Resulting    Soreness. 

CHAPTER    VII. 


OUTLINE  FORM.  Defined.— (Rules.)— Extend  to  Sound 
Enamel.— Obtain  Full  Length  Rod.s.— Self-Cleansing  Margins.— 
In  Relation  to  Developmental  Grooves. — Enamel  Eminences. — 
Avoid  Angles  in  Outline.— Outline  in  the  Embrasures.— 
Enamel  Margins.- Objects  of  Extension  for  Prevention.— Ex- 
tension for  Prevention  Does  Not  Mean.— Its  Maximum  Appli- 
cation.—Abuses  of  Extension  for  Prevention.— Extension  for 
Resistance.- Dangers   of   Increased   Cavity   Outline.— Illustrate. 


.50 


8  ESSENTIALS  OF  OPERATIVE  DENTISTRY 

CHAPTER    VIII 53 

resistance:  form.  Defined. — Resistance  Form  involves 
a  Consideration  Of. — Importance  Of. — Amount  of  Force  to  Pro- 
vide For. — Management  of  Weakened  Enamel  Walls. — Stress 
from  "Within. — Weakened  Walla  Allowed  to  Remain. — Impor- 
tance of  Flat  Seats  for  Fillings. — Example  Given. — In  Proximo- 
Occlusal  Cavities. — The  Step  as  a  Part  ot  Resistance  Form. — 
Extension  of  Margins. — Resistance  Form  as  Related  to  Filling 
Materials. 

CHAPTER    IX 55 

RETENTION  FORM.  Defined. — Partially  Provided  for  in 
Resistance  Form. — Cavities  Requiring  Maximum  Retention 
Form. — When  Not  Required. — Objects  of  Stepping. — Plane  of 
Flat  Seats. — Acute  Angles  Required. — Little  Resistance  in 
Enamel. — All  Retention  Laid  in  Dentine.  ' 

CHAPTER   X 57 

CONVENIENCE  FORM.  Defined.— Sparingljr  Used.— Maxi- 
mum Convenience  Form. — Minimum  Convenience  Form. — 
Abuses  Of. — Importance  of  Preliminary  Separation. — Starting 
Points  as  a  Part  of  Convenience  Form. — Where  Needed. 

CHAPTER    XI 58 

(A)  REMOVAL  OF  REMAINING  CARIOUS  DENTINE.  De- 
fined.— In  Large  Decays. — Where  Two  Large  Proximal  Cavi- 
ties.— Technic  of  Removal. — When  Exposed  Pulp  Is  Expected. 

(B)  FINISHING  ENAMEL  WALLS.  Defined.— Steriliza- 
tion.— Regarding  Moisture  on  Cavity  Walls. — The  Plane  of  the 
Enamel  Wall. — How  Accomplished. — The  Plane  of  the  Mar- 
ginal Bevel. — The  Depth  of  the  Marginal  Bevel. — Locations 
Subject  to   Great  Stress. 

(C)  TOILET  OF  THE  CAVITY.  Defined.— Means  of  Ac- 
complishment.— Regarding  White  Enamel  Margins. — Use  of 
Disks  or  Strips. — Use  of  Fluids  as  Disinfectants. — Leaks  in 
Rubber  Dam. — Dangers  in  a  Neglect  to  Have  Margins  Sur- 
gically Clean. — Regarding  Cases  Where  Cavity  Is  Prepared  at 
One  Sitting  and  Filling  Placed  at  Another. — The  Bearing  This 
Fact  Has  Upon  Inlays. — Conclusion  Rule. 


PART    I  I  I. 

CHAPTER    XII 63 

EXAMINATION  OF  THE  MOUTH  LOOKING  TO  DENTAl. 
SERVICES.  Dentist's  First  Duty.— Light  Hand.— Washing  the 
Hands. — Regarding  Linen. — Instruments  in  Sight. — After"  the 
First  Requests  Have  Been  Complied  With. — Regarding  the 
Alleviation  of  Pain. — Advice  as  to  Prophylactic  Treatment. — 
The  Making  of  a  Careful  Examination. — Instruments  Needed. — 
Use  of  Mouth  Mirror. — Use  of  Etxplorer.— Absorbent  Cotton. 
—Waxed  Floss  Silk. — The  Chip  Blower. — The  Mechanical  Sepa- 
rator.— The  Electric  Lamp. — Advice  as  to  Dental  Services 
Needed. 

CHAPTER    XIII 67 

THE  ALLEVIATION  OF  DEINTAL  PAINS.  Importance  of 
Immediate  Relief  of  Pain. — Importance  of  a  Correct  Diagnosis. 
— Regarding   the    Symptoms    First     Spoken     of    by     Patient. — 


CONTENTS  y 

Patient  Generally  Right  as  to  Symptoms. — Divisions  of  Dental 
Pains. — Symptoms  of  Pulp  Pains. — The  Treatment  Is  Varied. 
— Cold  Water  or  Air  Causes  Pain. — When  Warm  Fluids  Cause 
Pain  and  Cold  Relieves. — The  Treatment  in  Such  Cases. — Both 
Cold  and  "^'arm  Cause  Pain. — Treatment  of  Passive  Hyperemia. 
— Use  of  Revulsives. — Foreign  Substances  Cause  Pain. — Treat- 
ment.— Symptoms  of  Pericemental  Disease. — Treatment. — When 
Pus  Has  Formed. — Acute  Alveolar  Abscess  Treatment. — Assist- 
ing to  Point. 

CHAPTER  XIV 71 

PROPHYLACTIC  TREATMENT  CF  THE  MOUTH.  Import- 
ance of  Prophylactic  Treatment. — Effects  of  Unhygienic  Con- 
ditions Upon  the  Teeth. — Effects  Upon  Sub-Dental  Tissues. — 
Scope  of  Preventative  Dentistry. — Kinds  of  Deposits  Upon  the 
Teeth. — Those  Enemies  to  Tooth  Substance. — Those  Injurious  to 
Tissues  About  the  Teeth. — Source  of  Salivary  Calculus. — How 
Held  in  Suspension  in  the  Saliva. — Reason  for  Its  Precipitation. 
— Mouths  Most  Subject  to  Deposits  of  Salivary  Calculus. — 
Mouths  of  Public  Speakers. — Location  of  Salivary  Calculus. — 
Serumal  Calculus  Defined. — Amount  in  the  Blood. — Location 
of  Serumal  Deposits. — Also  Found  on  Unexposed  Portions  of 
Roots. — Size  of  Deposits. — Location  of  Green  Stain. — The  Color 
Is  Due  To. — Injury. — Reason  for  Green  Stain. — Injury  in  Neg- 
lect of  Removal. — Removal  of  Salivarj-  Calculus. — Push  Cut 
Method. — Pull  Cut  Method. — Order  of  Procedure. — The  First 
Teeth  to  Be  Scaled. — Proximal  Surfaces  Are  Best  Scaled. — 
Removal  of  Serumal  Calculus. — Calculus  Must  Be  Distinguished 
From. — Scaling  of  Roots. — Removal  of  Green  Stain. — Care  of 
Brush  WHieel  and  Instruments. — Removal  of  Soraes. — Import- 
ance of  Tooth  Brush. — Use  of  Hydrogen  Dioxide. — Benefits  of 
Gum  Massage. — Instructions  to  Patients. — Technic  of  Brush- 
ing.—The  Use  of  Floss  Silk. — Toothpicks. 

CHAPTER  XV 7S 

EXCLUSION  OF  MOISTURE.  Reasons  for  Excluding  Mois- 
ture.— Methods. — Objections  to  the  Use  of  Rubber  Dam. — Ef- 
fects of  Neglecting  Dryness. — One  Filling  Material  Where  Dry- 
ness Cannot  Be  Maintained. — Exclusion  of  Moisture  for  Sterili- 
zation.—For  Proper  Treatment  of  Root  Canals. — Injuries  to 
Cavity  W^alls. — Better  View  of  Cavity. — Observance  of  Extent 
of  Decalcification. — Less  Pain. — When  Using  Caustics. — As  a 
Time  Saver. — Best  Means  of  Securing  Dryness. — Size  of  Holes. 
— Distance  Between. — Location  of  Holes. — Number  of  Teeth 
Isolated. — With  Anterior  Teeth. — M'ith  Molars  and  Bicuspids. 
— Placing  of  the  Rubber  Dam. — Occlusal  Side  of  Dam  De- 
fined.— Gingival  Side  Defined. — Applying  Dam  to  Anterior 
Teeth. — Applying  Dam  to  Posterior  Teeth. — To  Prevent  Leakage 
Around  the  Teeth. — Use  of  Ligature. — Caution  in  the  I'^se 
of  Ligatures. — Ligatures  are  Made. — Cutting  of  the  Loose 
Ends. — Mo.st  Popular  Knot. — The  Wedelstaedt  Tie. — Removal 
of  Ligatures. — Where  Amalgam  Fillings  Have  Just  Been 
Placed. — Rule  for  Cutting  Ligatures. — The  Selection  of  Clamp. — 
Method  of  Af-plying  Clamp. — The  Use  of  the  Cervical  Clamps. — 
Six  Steps  in  Removal  of  Rubber  Dam. — The  Use  of  Absorbents. 

CHAPTER  XVr 8S 

THE  TREATMENT  <JV  HYPERSENSITIVE  DENTINE.  De- 
fined.— Sensitiveness  of  Normal  Dentine. — Means  of  Convey- 
ance to  Pulp. — Contents  of  Tubuli. — Direct  Cause  of  Sensitive 
Dentine. — Most  Common  Cause. — Degree  of  Sensitiveness  In- 
dicates Rjipicity  of  Decay. — Most  Sensitive  Parts  of  Cavities. — 
Mechanical  Abrasion. — Expo.sed  Cementum. — Abnormal  Secre- 
tions.— Poorly    Calcified    Teeth.— Teeth    Recently    Erupted. — In- 


10  ESSENTIALS  OP  OPERATIVE  DENTISTRY 

door  Living. — Mental  Strain. — Dealing  With  Various  Tempera- 
ments.— The  Irresponsible  Patients. — Cowardly  Patients. — Pa- 
tients Who  Make  Believe  They  Are  Suffering. — Five  Classes  of 
Agents  for  Relief  of  Sensitive  Destine. — Desiccation. — How 
Accomplished. — Cold  Air. — Moist  Heat  or  Cold. — Means  of  Ap- 
plying.— Effects  of  Applying  Heat  to  Any  Vital  Tissue. — Means 
of  Applying  Moist  Cold. — To  Lessen  Primary  Pain. — Electric 
Current  (Cataphoresis.) — Caution  in  the  Use  of  E'scharotics. — ■ 
Lime  Chloride. — Danger  in  Use  Of. — Methods  of  Using  Zinc 
Chloride. — Robinson's  Remedy. — Silver  Nitrate. — Cocaine. — 
Methods  of  Using. — Slow  Absorption  Method. — Pressure  Anaes- 
thesia.— High  Pressure  Syringe. — Phenol. — Method  of  Using. — 
Gil  of  Cloves. — Cloves  and  Phenol  Combined. — Potassium  Bro- 
mide.— Chloroform. — The  A.  C.  E.  Mixture. — Method  of  Admin- 
istering.— Rapid  Breathing. — Method  of  Using. — Sharp  Instru- 
ments.— ^Direction    of   Cut. 

CHAFTEK  XVII 99 

PROTECTION  OF  VITAL  PULP.  Sense  of  Normal  Pulp.— 
Effects  of  Loss  of  Protecting  Enamel. — Chief  Idiosyncrasy  of 
Pulp. — Recuperative  Powers  of  Pulp. — Capping  Pulp  Defined. — 
Indications  Requiring  Pulp  Protection. — Age  of  Patient. — Ad- 
vanced Age. — ^When  Large  Amount  of  Dentine  Is  Lost. — Loca- 
tion of  Tooth. — Length  of  Time  Exposed. — Stage  of  Hyperemia. 
— Four  Conditions  When  Pulp  Capping  Is  Demanded  and  Suc- 
cess May  Be  Expected. — Infected  Pulps. — General  Health  of 
Patient. — Plethoric  Patients. — In  Deep  Seated  Cavities. — Four 
Requirements  of  Material  Used  in  Pulp  Protection. — In  Pro- 
gressive Caries. — Treatment  Of. — Second  Class  Defined. — Treat- 
ment.— Third  Class  Defined. — Treatment. — Fourth  Class  Defined. 
— Treatment. — Pulp  Preservers  and  Mummifiers. — Gutta-percha 
as  a  Pulp  Capping. 

CHAPTER  XVIII .107 

PULP  DEVITALIZATION  AND  REMOVAL.  Reasons  for 
Devitalization. — Two  Causes  for  Diseased  Pulps. — Ways  Bac- 
teria Enter  Pulp. — Removal  of  Cause. —  Traumatic  Injury. — 
Abnormal  Thermal  Stimuli. — Reasons  for  Abnormal  Thermal 
Changes  Reaching  the  Pulp. — Lack  of  Normal  Thermal  Stimuli. 
— Peripheral  Nerve  Irritation. — Location  of  Irritation. — Four 
Requirements  of  a  Devitalizing  Agent. — Methods  of  Pulp  De- 
vitalization.— To  Determine  the  Method  to  Employ. — Anestheti- 
zation of  Pulp.  Defined. — Three  Conditions  When  Anesthetiza- 
tion Is  Indicated. — Technic  of  Operation  Where  Cavity  Exists. 
— Where  High  Pressure  Syringe  Is  Indicated. — Technic  in  Its 
Use. — An  Essential  Point. — Where  Great  Care  Should  Be  Ex- 
ercised.— Technic  of  Removing  an  Anesthetized  Pulp. — To 
Check  Hemorrhage. — Cause  of  Discoloration. — -Post-Extirpation 
Pains  Prevented. — The  Best  Practice  as  Subsequent  Treatment. 
— Regarding  Immediate  Root  Filling. — Devitalization  With  Ar- 
senic Trioxide. — Formula  for  Arsenious  Mixture. — Technic  of 
Application. — Amalgam  as  a  Retainer. — Cement  as  a  Retainer. — 
Temporary  Stopping  as  a  Retainer. — Cotton  as  a  Retainer. — 
Caution  in  the  Use  of  Arsenic. — Length  of  Time  Application 
Should  Remain. — Regarding  Primary  Soreness. — Secondary 
Soreness. — Treatment  for  Arsenical  Poisoning. — V^^hen  Pulp  Re- 
turns Partially  Devitalized. — Technic  of  Pulp  Removal. — Re- 
garding Immediate  Root  Following  Arsenical  Devitalization. — 
Regarding  Dryness  in  Root  Canal   Treatment. 

CHAPTER    XIX IIT 

MANAGEMENT  OF  PUTREISCENT  ROOT  CANALS.  Pu- 
trescent Root   Canals   Defined. — Putrefaction   Defined. — Naming 


CONTENTS  11 

End  Products. — The  Necessity  for  the  Presence  of  Bacteria. — 
Four  Classes  of  Putrescent  Root  Canals. — Treatment  of  All 
Classes  Consists  Cf. — Symptcms  of  Open  Putrescence. — Treat- 
ment.— Technic  of  Applying  Phenolized  Iodoform. — Chief  Ob- 
jection to  This  Method  of  Treatment. — Cases  of  Long-  Standing. 
— Consistency  of  Animal  Pats. — Their  Removal  Is  Accomplished. 
— Sym.ptoms  of  Closed  Putrescence. — Treatment  of  Closed  Pu- 
trescence.— Antogenous  Putrescence. — Symptoms  of  Complicat- 
ed Putrescence. — Treatment. — Treatment  in  Cases  of  Acute 
Codnplication. — Treatment  of  Chronic  Complications. — Treat- 
ment of  So-Called  "Blind  Abscesses." — Alveolar  Abscesses  With 
Chronic    Fistula. — Treatment.— So-Called    Pyogenic    Membrane. 

CHAPTEK    XX 125 

THE  FILLING  OF  ROOT  CANALS.  The  Necessity  for  Fill- 
ing Root  Canals. — When  a  Root  Canal  Is  Ready  for  Filling. — • 
The  Perfect  Root  Filling. — Requirements  of  a  Material  for  Fill- 
ing Root  Canals. — The  Objective  Point  in  Root  Canal  Filling.— 
The  Difficulties  With  Small  Root  Canals. — Best  Means  of 
Cleansing. — Management  of  Bent  Root  Canals. — Ktind  of  Broach. 
— Cotton  Carrying  Broach. — Applying  the  Cotton. — Leaving  the 
Cotton  in  Canal. — Most  Popular  Root  Canal  Filling. — Methods  of 
Use. — First  Step  in  the  Operation. — Objects  in  Using  E'uca- 
lyptol. — Introducing  the  Chlora-percha. — Introducing  the 
Canal  Point. — The  Size  of  the  Point. — Slight  Flinching  in  Cases 
of  Recent  Devitalization. — Not  Sought  in  Putrescent  Cases. — 
Regarding  Fillins;  Pulp  Chambers  With  Gutta-percha. 

CHAPTER    XXI 129 

EXTRACTION  OF  PERMANENT  TEETH.  General  Consid- 
eration.— Principal  Retention. — Opening  Mouth  of  Alveolus. — 
How  Accomplished. — Three  Forces  Employed. — Traction. — Ro- 
tation.— Pressure. — Position  and  Movements. — Securing  Pa- 
tient's Confidence. — Position  of  Patient's  Head.— With  Superior 
Teeth. — Position  in  Extracting  Lower  Teeth. — Position  of  Op- 
erator's Hands. — Operating  at  Arm's  Length. — Overcoming  Re- 
sistance of  Patient. — Rule  for  Extracting  Superior  Central  and 
Lateral  Incisors. — Traction  Defined. — Why  Rotation. — Pressure. 
— Regarding  Alternate  Pressure. — Rule  for  Inferior,  Central  and 
Lateral  Incisors. — Traction. — Rotation. — Pressure.  —  Superior 
Cuspid.s. — Traction. — Rotation. — Pressure. — Mesio-Distal  Grasp. 
— Rules  for  inferior  Cuspid. — Rules  for  Superior  Bi-cuspids. — 
Caution. — Inferior  Bi-cuspids. — Regarding  Line  of  Traction. — 
Caution  as  to  Injury  to  Upi)er  Teeth. — Rule  for  Superior  First 
and  Second  IVJioIars. — Regarding  Pressure. — Inferior  First  and 
Second  Molars. — A  Common  Error.— Superior  Third  Molars. — 
Inferior  Third  Molars. — Caution. — Author's  Formula  for  Local 
Anaesthetic. — Caution  When  Pus  Is  Present.— Hemorrhage  Fol- 
lowing Tootn  Extraction. — In  Mild  Cases. — In  Severe  Cases. — 
Method  of  Applying  Leather  Scrapings. — Surgical  Means. — 
Technic  of  Ligating  Inferior  Dental  Artery. — Adrenalin  Chlor- 
ide Hypodermically. — Capillary  Hemorrhage. 

CHAPTEK  XXII 140 

EXTRAf'TlON  OF  TEMPORARY  TEETH.  Most  Important 
Con.sideration. — Results  of  Disregarding  Order. — First  Perma- 
nent Tooth  to  PJrupt. — Regarding  Ignorance  of  Public  Pertain- 
ing to  This  Fact— Duty  of  Dentists  in  This  Case.— Reasons  for 
a  Permanent  Tooth  at  This  Time.— Effects  of  Early  Extraction 
of  Second  Temporary  Molar. — Irregularity  Resulting. — Further 
Development. — Artistic  Facial  Contour. — Order  in  Which  Tem- 
porary Teeth  Are  Reiilaced. —Inferior  Teeth  Precede  the  Su- 
perior.— Difference    in    Time   of    Eruption    as    to    Sex. — Compare 


12  ESSENTIALS  OF  OPERATIVE  DENTISTRY 

Order  of  Eruption. — Reason  for  Change  in  Order. — Loss  of 
Temporary  Cuspid. — Evil  Resulting  From  a  Disregard  of  the 
Order  in  Which   the   Temporary  Teeth  Are  Replaced. 

CHAPTEE  XXIII 147 

MANAGEMENT  OF  PIT  AND  FISSURE  CAVITIES.  CLASS 
I.  Location. — Predisposing  Cause. — Extension  for  Prevention 
Not  Necessary. — Tendency  to  Extensive  Dentinal  Decay. — In- 
cipient Decays  in  Occlusal  Defects. — Technic  of  Outline  Form. 
— Use  of  the  Chisel. — Resistance  Form. — Retention  Form. — Con- 
venience Form. — Removal  of  Remaining  Decay. — The  Walls. — 
Disinfection. — Finish  of  Enamel  W'alls. — Toilet  of  the  Cavity. — 
Inlays  Class  I  Small. 

CHAPTER   XXIV-.- 151 

MANAGExMBNT  OF  PIT  AND  FISSURE  CAVITIES.  (Con- 
cluded.) Large  Cavities  in  Central  Fossa  of  Molars. — Outline 
Form. — When  Pulp  Exposure  Is  Feared. — Placing  the  Rubber 
.  Dam. — Wlien  the  Pulp  Is  Exposed. — Resistance  and  Retention 
Forms. — Avoiding  the  Flattening  of  Pulpal  Wall,  First  and 
Second  Means. — Convenience  Form. — Convenience  Points. — Fin- 
ish of  Enamel  Walls  and  Toilet. — Pit  Cavities  in  Buccal  and 
Lingual  Surfaces  of  Molars. — Outline  Form. — Resistance  Form. 
— Extension  for  Prevention. — Retention  Form. — Finish  of 
Enamel  Walls. — Pit  Cavities  in  Lingual  Surface  of  Upper  In- 
cisors.— Early  Attention.- — Instrumentation. — Outline  Form. — 
Retention   and   Resistance   Form. — Inciso-Occlusal    Line   Angle. 

CHAPTER  XXV 156 

MANAGEMENT  OF  PROXIMAL  CAVITIES  IN  BI-CUSPIDS 
AND  MOLARS.  CLASS  II.  Location. — Predisposing  Cause. 
— Elarly  Detection  Essential. — Small  Proximal  Cavities  De- 
scribed.— Gaining  Access  First  Method. — Second  Method. — 'Third 
Plan. — Preliminary  Sei>axation,  Means  Of. — Outline  Fc|rm. — 
Six  Cases  When  Step  May  Be  Omitted. — Outline  of  Cavity 
Proper. — A  Good  Rule  to  Follow  in  Extension  for  Prevention. — 
Extensions  Gingivally. — Axio- Gingival  Angles. — Gingival  Out- 
line.— Forming  the  Step. — Area  Included. — Avoiding  Angles  in 
Outline. — Resistance  and  Retention  Forms. — Buccal  and  Lin- 
gual Walls.— Axial  Wall.— Pulpal  Wall.— Line  Angles.— Con- 
venience Form. — Inlays. — Finish  of  Eiiamel  Walls. — Toilet  of 
the  Cavity. 

CHAPTER   XXVI 163 

MANAGEMENT  OF  PROXIMAL  CAVITIES  IN  BI-CUS- 
PIDS AND  MOLARS.  CLASS  H.  (Concluded.)  Large  Prox- 
imal Cavities  Described. — Danger  of  Pulp  Exposure. — Outline 
Form. — Extension  for  Prevention. — Gingiva.!  Outline. — Occlusal 
Outline. — Removal  of  Remaining  Decay. — Technic  of  Remov- 
ing.— Resistance  and  Retention  Forms. — The  Gingival  Wall. — 
Pulp  Protection. — Finish  of  Enamel  Walls. — Toilet  of  Cavity. — 
Large  Proximal  Devital. — Outline  Form  With  Molars. — Outline 
Form  With  Bi- Cuspids. — In  M.  O.  D.  Cavities. — In  Extremely- 
Frail  Walls. — Resistance  and  Retention  Forms. — Convenience 
Form. — Neglected  Access  Form. — Toilet  of  the  Cavity. — Dan- 
gers of  Over  Desiccation. 

CHAPTER    XXVII 169 

MANAGEMENT  OF  PROXIMAL,  CAVITIES  IN  INCISORS 
AND  CUSPIDS  NOT  INVOLVING  THE  ANGLE.  CLASS  III. 
Defined. — Exception. — General  Form  of  Class  III. — Location  of 
Primary    Decay. — Opening   the    Cavity. — Gaining   Access. — Out- 


CONTENTS  13 

line  Form. — Gingival  Outline. — Incisal  Outline. — Labial  Out- 
line.— Additional  Extension. — Lingual  Outline. — Resistance 
Form. — Retention  Form. — Incisal  Line  Angle. — Describing  Re- 
tention Form  of  Class  III. — Difference  Between  Shallow  and 
Deep  Class  III. — Other  Point  Angles. — Line  Angles. — The  Axio- 
Labial  Line  Angle. — The  Axio-Lingual  Line  Angle. — Gingio- 
Axial  Line  Angle. — Gingio-Labial  and  Gingio-Lingual  Line 
Angles. — Gingival  Wall. — Convenience  Form. — Removal  of  Re- 
maining Decay. — Finish  of  Enamel  Walls. — Devital  Cases. — 
Distal  of  Superior  Cuspids. — Access. — Outline  Form. — The  Step. 
— Axial  Walls. — The   Lingual-Axial   Wall. — Convenience   Form. 

CHAPTER  XXIII 176 

MANAGEJNIEINT  OF  PROXIMAL  CAVITIES  IN  INCISORS 
IN\^OLVING  THE  ANGLE.  CLASS  IV.  Defined.— Four  Con- 
ditions Requiring  Angle  Restoration. — Difference  Between  Me- 
sial and  Distal  Surfaces. — First  Plan  of  Angle  Restoration. — The 
Gingival  Point  Angles. — The  Labial  Outline. — Rule  for  Labial 
Outlines  in  General.— The  Necessity  for  Curving  to  the  Axial. — 
Lingual  Outline. — With  Lower  Incisors. — Second  Plan  Class  IV 
Described. — Incisal  Edge. — The  Depth  of  the  Step. — Technic  of 
Cutting  Step. — Point  Angle  in  Step. — When  Second  Plan  Is  In- 
dicated.— Third  Plan  Class  IV  Described. — Indication  For. — 
Labial  Outline. — Fourth  Plan  Class  IV  Described. — Objects  of 
Its  Use. 

CHAPTER  XXIX 1S3 

MANAGEMENT  OF  CAVITIES  IN  THE  GINGIVAL  THIRI). 
CLASS  V.  Chief  Differences  as  to  Origin. — Their  Prevention. 
— Tendency  to  Spread. — Gingival  Outline. — Retention  Form. — In 
Large  Buccal  Decays. — If  Pulp  Is  Involved. — When  Gold  Is 
Used. — 'With    Labial    Cavities. 

CHAPTER  XXX 180 

MANAGEMENT  OF  ABRADED  SURFACES.  OCCLUSAL 
AND  INICISAL.  CLASS  VI.  Defined  and  Described.— Cause 
— Object  in  Filling. — Occlusal  Surfaces. — E&rly  Restoration  of 
Cusps. — Cavity  Preparation. — Single  Molars  Affected. — If  Con- 
tact Point  Has  Been  Reached. — When  Wear  Is  General. — In- 
cisal Abrasion. — Amount  of  Surface  Requiring  Protection. 

CHAPTER  XXXI 189 

CAVITY  PREPARATION  FOR  GOLD  INLAYS.  Inlay  De- 
fined.— Six  Indications  for  Gold  Inlays. — Contra-Indications.— 
Change  In  Order  of  Procedure. — Order  Named  as  Applied  to 
Inlay  Work. — Gaining  Access. — Resistance  Form  for  Inlays. — 
Convenience  Form  for  Inlays. — Finishing  of  the  Enamel  Walls. 
— Toilet  of  Cavity  for  Inlays. — Line  of  Approach. — Outline 
Form. — Resistance  Form. — Retention  Form. — Preparation  of 
Cavities  Class  II. — Outline  Form. — Resistance  Form. — Finish 
of  Enamel  Walls. — Retention  Form. — Cavities  Class  III. — Ac- 
cess.— Outline  Form. — Cavities  Class  IV. — Preferable  Plans. — 
Only  Change  in  Cavity  Preparation. — Cavities  Class  V. — Oc- 
cluBal   Wall.— Cavities   Class  VI. 

CHAPTER   XXXII 195 

THE  MAKING  AND  SETTING  OF  A  GOLD  INLAY.  The 
Objects  of  the  Inlay. — History. — Method  Using  Wax  Model. — 
Making  the  Model. — Use  of  Rubber  Dam  to  Lower  Model. — 
Conditions  as  to  Margins. — Placing  the  Sprue  Wire. — Giving  the 
Wax  Model  Retention  Form. — Method  Using  Wax  Model  Pin 
Attached. — Placing   the   Pin. — Method   Using   Pure   Gold   Matrix, 


14  ESSENTIALS  OF  OPERATIVE  DENTISTRY 

Pin  Soldered  on  Casting  the  Contour. — Technic  of  Construction. 
— Making-  the  Wax  Contour. — To  Restore  Occlusal  and  Incisal 
Surfaces. — ^Gauge  of  Pins. — Gauge  of  Gold  Matrix. — Method  of 
Sweating  the  Contour. — Making  the  Matrix. — Sweating  the 
Contour. — Method  Using  Sponge  Gold  as  Model. — 'Preparation 
of  Waxed  Gold. — Making  the  Model. — Investing. — Saturating 
the  model. — Finishing  Gold  Inlays. — Correction  of  Defects. — 
Setting  a  Gold  Inlay. — Final  Finish. 

CHAPTER   XXXIII 204 

MANIPUIiATION  OF  COHESIVE  GOLD  IN  THE  MAKING 
OF  A  FILLING.  Physical  Properties  Desired  in  a  Filling 
Found  in  Gold. — Objectionable  Qualities  of  Gold. — Welding  of 
Gold. — Permanent  Injury  to  Gold. — How  Protected. — Annealing 
Gold. — Degree  of  Heat. — Best  Method  of  Annealing. — Next  Best 
Means. — Wrong  Methods  of  Annealing. — Specific  Gravity  Corn- 
Pared. — Cohesion  of  Gold  Theories  Of. — Reason  for  Using  Ser- 
rated Plugger  Points. — Bridging  Defined. — Same  Sized  Serra- 
tions of  Advantage. — Rotating  Plugger  Avoided. — Size  of  Plug- 
ger Point. — Preparation  of  the  Foil. — Application  of  Foil. — 
Forces  Used  in  Condensing  Gold. — Illustrated. — Hand  Pres- 
sure Alone. — Mallet  Force  Alone. — Best  Force- — Pi.ule  as  to 
Load  and  Velocity. — Hand  Mallet. — Automatic  Mallet. — Power 
Mallet. 

CHAPTER    XXXIV 211 

MANIPULATION  OF  COHESIVE  GOLD  IN  MAKING  FILL- 
INGS BY  CLASSES.  Reason  for  Being  Easy  to  Fill. — Plan  of 
Starting  the  Gold  in  Class  I. — In  Occlusal  Cavities. — Order  of 
Stepping  in  Buccal  Cavities. — When  Cavity  Has  Long  Irregular 
Outline. — Preparation  of  Class  II  for  Starting  the  Filling. — 
First  Plan  of  Starting. — Second  Plan. — Third  Plan. — Order  of 
Stepping  the  Plugger  Point. — When  Gold  Extends  Beyond  Con- 
tour.— Progress  of  the  Filling. — Covering  the  Pulpal  Wall  First 
Plan. — Second  Plan. — Building  at  Contact  Point. — Position  of 
Contact  Point. — Marble  Contact. — When  to  Move  Contact  Flush 
to  Occlusal. — Half  Marble  Contact. — Effects  of  Occlusal  Wear 
to  Contact  Point. — Placing  Last  Portions  of  Gold. — Filling  Class 
II  With  Matrix  in  Position. — When  to  Adjust  Matrix. — When  to 
Remove  Matrix. — Use  of  Separator  Class  II. — Starting  the  Gold 
Class  III. — Care  as  to  Covering  the  Lingo-Gingival  Angle. — 
Filling  of  Incisal  Angle. — Lingual  Approach  Class  III. — When 
Advised. — Advantage  of  Class  IV  as  to  Angle  of  Plugger  Point. 
— Starting  of  Class  IV. — Final  Portions  of  Gold. — As  to  the 
Layers  of  Gold  With  Reference  to  Lines  of  Fracture. — Rules 
for  Class  V. — Building  of  Class  VI 

CHAPTER    XXXV 218 

FINISHING  GOLD  FILLINGS.  Regarding  Secondary  Con- 
densation.— Burnishing. — The  Order  to  Follow  in  Finishing  a 
Filling. — Means  of  Reducing  Bulk. — Last  Place  to  Receive  At- 
tention.— Regarding  the  Use  of  a  Saw  in  the  Proximal.— Re- 
moving Excess  at  the  Gingival. — Use  of  the  Finishing  Knife, 
—When  to  Abandon  the  Use  of  Coarse  Abradents.— Finishing 
Strips  in  the  Proximal. — When  Entire  Cavity  Outline  Has  Been 
Found.— Last  Attention  to  Contact  Point. — Means  of  Final 
Finish. 

CHAPTER    XXXVI 221 

MANIPULATION  OP  AMALGAM  IN  THE  MAKING  OF  A 
FILLING.  Amalgam  Defined. — Most  Commonly  Composed  of 
Mercury  and  Two  or  More  Other  Metals. — History. — Regarding 
Reception. — Relative  Position  of  Amalgam  as  a  Tooth  Saver.— 


CONTENTS  15 

The  Valuable  Properties  of  Amalgam. — Objections  to  Amalgam. 
— That  Which  Controls  Extent  of  Contraction  and  Expansion. — 
Flow  of  Metals  De.fmed. — Peculiarity  of  Amalgam. — Edge 
Strength  Defined. — Edge  Strength  of  Amalgam  Fillings  Depend 
Upon  Four  Things. — When  Maximum  Edge  Strength  Will  Be 
Obtained. — Regarding  the  Length  of  Time  an  Alloy  Stands. — 
Aged  Alloys  as  Related  to  "\''ariation  in  Expansion  Contraction 
Range. — Methods  of  Annealing  Alloys. — Effects  of  Annealing. 
- — Giving  Formula  Showing  T-east  Expansion  and  Contraction 
When  Unannealed. — Effects  Upon  an  Alloy  by  Adding  Five  Per 
Cent  of  Gold. — Five  Per  Cent  Platinum. — Five  Per  Cent  Copper. 
— Five  Per  Cent  Zinc. — Cavity  Preparation  for  Amalgam. — Ac- 
cess Form. — Outline  Form. — Flat  Seats  for  Fillings. — Breadth 
of  Occlusal  Step. — Regarding  Use  of  Rubber  Dam. — The  Matrix. 
— ^Wedging  at  Gingival. — Thickness  of  Matrix. — Separation. — 
Testing  Alloys. — Making  the  Mix. — Wringing  Out  Excess  Mer- 
cury.— Amalgam  Pluggers. — Making  the  Filling. — Use  of  Bur- 
nishers.— Trimming  Amalgam  Fillings. — Removing  the  Matrix. 
— Cutting  of  Amalgam  From  Tooth  to  Margins. — Contact 
Point. — Polishing  the  Filling. 

CHAPTER    XXXVII ii29 

THE  USE  OF  CMMENTS  IN  FILLING  TEETH.  Varieties 
of  Cement. — Cavity  Preparation  For. — The  Cylicate  Cements. — 
Oxyphosphate  of  Zinc. — Its  Chief  Fault. — Oxychloride  of  Zinc. 
— Use  of  Sulphate  of  Zinc. — Oxyphosphate  of  Copper. — Manipu- 
lation of  Oxyphosphate  of  Zinc   Cement. — Plan  of  Spatulating. 

CHAPTER  XXXVIII 232 

TILE  USE  OF  GUTTA-PERCHA  IN  FILLING  TEETH.  The 
Good  Qualities  of  Gutta-percha. — Best  Form  to  Use. — As  a 
Cavity  Stopping. — For  Impacted  Third  Molars. — Cavity  Prepa- 
ration For. — Method  of  Placing  Filling. — As  a  Root  Filling. — 
For  Canal  Points. — Use  in  Slow  Separation. — Temporary  Stop- 
ping. 

CHAPTER    XXXIX 234 

TIN  AS  A  FILLING  MATERIAL.  History.— Dr.  W.  C.  Bar- 
rett's Opinion  Of. — Therapeutic  Value  of  Tin. — Due  To. — Dis- 
coloration.— Amount  of  as  Related  to  Permanency. — Thermal 
Conductivity. — In  Rapid  Decay. — Tin  in  the  Teeth  of  Children. 
— Cavity  Preparation  for  Tin. — Forms  of  Tin. — Methods  of  In- 
troduction.— Tin  and  Gold. — Tin  and  Amalgam. — In  Bifurcated 
and  Punctured  Roots. 

CHAPTER  XL 238 

COMBINATION  FILLINGS.  Defined.— Objects  of  Combina- 
tion.— Single  Materials  Used  as  a  Filling. — Gold  and  Tin  Com- 
bination.— Benefits  Derived. — Gold  and  Cement. — Two  Methods 
of  Combining. — When  Indicated. — Gold  and  Platinum. — Rules 
for  Conden.sation. — Cohesive  and  Non-Cohesive  Gold  Combina- 
tion.— Cement  and  Amalgam. — Benefits. — Where  Indicated. — 
Cement  and  Porcelain. 

CHAPTER  XLI 241 

THE  USE  OF"  PORCELAIN  IN  POLLING  TEETH.  Porce- 
lain Inlay  Defined. — Dental  Porcelain  Defined. — Composition  of 
Porcelain. — Silex  Defined. — Kalin  Defined.— Feldspar  Defined. — 
Pigments  Defined. — High  Fusing  Porcelain  Defined. — Low  Pos- 
ing Defined. — The  Effects  of  Fusing  at  a  Lower  Temperature 
and    for    a    Longer    Time. — To    Make    Low    Fusing    Porcelain 


16  ESSENTIALS  OF  OPERATIVE  DENTISTRY 

From  High  Fusing  Body. — Building  by  Layers. — High  Biscuit 
Fuse  Defined. — Effects  of  Fine  Grinding. — Size  of  IVTass.^ 
Effects  of  Amount  of  Flux. — Shrinkage  in  Fusing. — Spheroiding. 
— Basal  Body  Defined. — Foundation  Body  Defined. — Enamel 
Body  Defined. — The  Advantage  of  the  Porcelain  Inlay. — Dis- 
advantages.— Degree  of  Cavo-Surface  Angle.— Indications  for 
Porcelain  Filling. — When  in  Class  I. — Class  III  and  IV. — Class 
V. — Class  VI. — Contra  Indications. 

CHAPTER  XLII 245 

PREPARATION  OF  CAVITIES  FOR  PORCELAIN  INLAYS. 
Access  Form. — Outline  Form  For. — Extension  for  Resistance  to 
Stress. — Resistance  Form. — Retention  Form. — Convenience 
Form. — Finish  of  Enamel  Walls. — Toilet  of  Cavity. — Secondary 
Cavity  Toilet. — Preparation  of  Cavities  Class  I. — Avoiding 
Exact  Circle. — The  Axial  Wall. — The  Surrounding  Walls. — 
Preparation  of  Cavities  Class  III. — Division  as  to  Line  of  Ap- 
proach.— Labial  Approach. — The  Gingival  Wall. — Axial  Wall. — 
Lingual  Approach. — To  Resist  the  Tipping  Strain. — Proximal 
Approach. — Preparation  of  Cavities  Class  IV. — Proximal  Ap- 
proach Class  IV. — Breaking  Cement  Line  on  Incisal  Edge. — 
Class  IV,  Plan  II.— Class  IV,  Plan  III.— Class  IV,  Plan  IV.— 
The  Treble  Step,  Class  IV. — Cavities,  Class  V. — Outline  Form. — 
— Cavities  of  Horse-Shoe  Form. — Point  to  Be  Observed. — Res- 
toration of  Incisal  Edge. — -Filling  a  Notch. — Restoring  Entire 
Incisal  Edge. — Outline  Form. — Retention  by  Pins  Vital  Cases. 
— In  Pulpless  Teetli. — Malformed  Enamel. 

CHAPTER  XIIII 253 

THE  CONSTRUCTION  AND  PLACING  CF  A  PORCELAIN 
INLAY.  Matrix  Defined. — Matrix  Material. — Thickness  of 
Foil. — Annealing  Matrix  Material. — Methods  of  Forming  the 
Matrix. — Technic  of  Combination  Method. — Removal  of  Im- 
pression.— Use  of  Damp  Cotton  Balls. — To  Facilitate  Handling 
Matrix. — Removal  of  Matrix.^ — Use  of  Gum  Camphor  and  Cast- 
ing Wax. — Wood  as  an  Impression. — Taking  the  Spring  Out  of 
the  Matrix. — Selection  of  Porcelain. — Delicate  Shades  Are  Se- 
cured By. — Applying  the  Porcelain  to  the  Matrix. — Torn 
Matrix. — Adding  the  Enamel. — Technic  of  Fusing. — Grinding  to 
Contour. — Removing  the  Matrix. — Etching  Cavity  Side  of  Inlay. 
— Toilet  of  Inlay. — Toilet  of  Cavity. — Technic  of  Setting  Inlay. 
— Finishing. 

CHAPTER    XIIV 260 

MANAGEMENT  OF  CHILDREN'S  TEETH.  The  First  Dif- 
ficulty.—The  First  Visit  to  the  Dentist. — The  Second  Difficulty. 
— Importance  of  Early  Attention. — Oral  Hygiene  With  Chil- 
dren.— Frequent  Visits  Necessary. — Length  of  Time  at  Each 
Sitting. — Filling  Materials  to  Be  Used. — Cavity  Preparation. 
— Extension  for  Prevention. — Cavities,  Class  I. — Class  II. 
WTien  Two  Proximal  Cavities  Exist. — Treatment  of  Exposed 
Pulps. — Treatment  of  Abscessed  Deciduous  Teeth. — Inter- 
Proximal  Grinding. — Management  of  Permanent  Teeth  in 
Childhood, — Necessity  for  Extra  Vigilance  Regarding  First 
Permanent  Molars. — Treating  First  Permanent  Molars. — A 
Good  Root  Filling  in  Such  Cases. — Great  Care  in  the  Use  of 
Arsenic. 


PART  ONE. 


CHAPTER.  I. 
Review  of  Tooth  Nomenclature. 

The  human  denture  is  that  of  the  omnivorous,  as  it  is  made 
up  of  such  shaped  teeth  that  the  food  of  both  the  carnivorous 
and  herbivorous  animals  is  successfully  masticated. 

Occlusion  is  the  term  applied  to  the  position  assumed  by 
the  teeth  when  in  a  state  of  rest  or  shut  against  the  teeth  of 
the  opposing  jaw. 

Articulation  is  the  term  applied  to  the  movements  of  the 
teeth  of  one  jaw  against  the  teeth  of  the  opposing  jaw,  made 
necessary  to  facilitate  the  function  of  mastication. 

There  are  two  dentures  known  as  temporary  and  perma- 
nent. 

The  temporary  denture  is  composed  of  twenty  teeth,  which 
are  replaced  by  the  second  dentition  or  permanent  set. 

They  are  named  as  follows:  Central  incisor,  lateral  incisor, 
cuspid,  first  molar  and  second  molar.  There  are  four  of  each 
named,  one  on  either  side  of  the  median  line  in  both  upper 
and  lower  jaws. 


Figure  1.     Left  lateral  half  of  deciduous  denture. 


(2) 


18 


ESSENTIALS  OF  OPERATIVE  DENTISTRY 


The  median  line  of  the  mouth  is  the  anterior  border  of  the 
antero-posterior  perpendicular  central  plane  of  the  body. 

The  permanent  denture  is  composed  of  thirty-two  teeth, 
twenty  of  which  are  erupted  to  take  the  place  of  lost  tem- 
porary or  deciduous  teeth. 

They  are  named  as  follows,  beginning  at  the  median  line : 
Central,  lateral,  cuspid,  first  bi-cuspid,  second  bi-cuspid,  first 
molar,  second  molar  and  third  molar.  There  are  four  of 
each,  one  on  either  side  of  the  median  line  in  both  upper 
and  lower  jaws. 


Figure  2.     Right  lateral  half  of  permanent  denture. 

The  first  permanent  tooth  to  erupt  is  the  first  molar,  all  four 
of  which  should  be  in  position  before  the  shedding  process  of 
the  deciduous  teeth  begins. 

The  physical  divisions  of  a  tooth  are,  crown,  neck  and  root. 


Figure  3.     Left  superior  cuspid  showing  physical   divisions. 
A,  Crown.     B,  Neck.     C,  Root.     D,  Apex. 


REVIEW  OF  TOOTH  NOMENCLATURE  19 

The  crown  is  that  portion  of  a  tooth  of  which  the  external 
surface  is  enamel  and  normally  protrudes  from  the  alveolus. 

The  root  is  that  portion  of  a  tooth  of  which  the  external 
surface  is  cementum  and  is  usually  fixed  in  the  alveolus. 

The  alveolus  is  the  cavity  in  the  projection  of  the  maxillary 
bones  which  envelope  the  roots  of  the  teeth  and  forms  their 
support  and  accomplishes  their  retention  in  service. 


Figure  4.     Showing  alveoli. 

The  neck  is  that  point  which  corresponds  to  the  junction  of 
the  crown  and  root,  is  slightly  constricted  and  is  outlined  by 
the  junction  of  the  enamel  and  cementum  which  is  termed 
the  gingival  line  or  cervix. 

The  apex  of  the  root  is  the  terminal  end  most  distant  from 
the  crown  and  is  the  seat  of  one  or  more  openings  called  the 
apical  foramen,  which  transmits  the  nerves  and  blood  vessels 
of  the  pulp. 

The  crowns  of  the  incisors  and  cuspids  have  four  surfaces 
and  an  ediic  They  are  the  mesial  surface,  distal  surface,  labial 
surface,  lingual  surface  and  the  incisive  edge. 

The  surfaces  of  the  crowns  of  tlic  bi-cuspids  and  molars  are, 
mesial,  distal,  buccal,  lingual  and  occlusal,  the  latter  being 
that  surface  which  comes  in  contact  with  the  teeth  of  the  op- 
posing jaw. 


20  ESSENTIALS  OF  OPERATIVE  DENTISTRY 

An  axillary  surface  is  one  which  is  parallel  with  the  long  axis 
of  the  tooth. 

The  proximal  surfaces  are  those  which  lie  against  the  proxi- 
mating  teeth.  That  towards  the  median  line  following  the 
curve  of  the  arch  is  called  the  mesial  and  that  most  distant 
from  the  median  line  is  called  the  distal. 

Contact  point  is  where  the  surface  of  a  tooth  touches  an  ad- 
joining tooth. 

Each  surface  is  divided  into  thirds  in  either  one  of  two  direc- 
tions, resulting  in  nine  divisions  which  materially  facilitates  in 
more  exactly  locating  a  specific  portion  of  a  given  surface. 

To  illustrate.  The  four  axial  surfaces  of  the  molars  and  bi- 
cuspids are  divided  into  the  gingival,  middle  and  occlusal 
thirds.  Then  again,  transversely,  the  mesial  and  distal  sur- 
faces are  divided  into  the  buccal,  middle  and  lingual  thirds, 
while  the  transverse  divisions  of  the  lingual  and  buccal  sur- 
faces are  mesial,  middle  and  distal  thirds.  The  occlusal  sur- 
face is  divided  mesio-distally  into  the  mesial  third,  middle 
third  and  distal  third,  and  buccal,  middle  and  lingual  thirds. 

Two  kinds  of  angles  are  found  on  the  surface  of  teeth  :  Line 
angles  and  point  angles. 

A  line  angle  is  formed  where  two  surfaces  meet  along  a  line. 

A  point  angle  is  formed  where  three  surfaces  come  together 
forming  a  corner  as  the  corner  on  the  external  surface  of  a  box. 

When  a  line  angle  is  parallel  with  the  long  axis  of  the  tooth 
it  is  called  an  axial  line  agle. 

The  marginal  ridges  of  the  molars  and  bi-cuspids  are  formed 
by  the  junction  of  the  axial  surfaces  with  the  occlusal  surface 
and  are  named  after  the  axial  surface  entering  into  the  forma- 
tion as,  the  mesial  marginal  ridge  and  the  distal  marginal 
ridge. 

All  other  line  angles  and  point  angles  are  named  by  joining 
the  names  of  the  surfaces  which  come  together  to  form  that 
particular,  angle. 

To  illustrate.  Mesio-labial  line  angle  as  found  in  the  in- 
cisors.     Disto-buccal    as    in    molars    and    bi-cuspids.      Disto- 


REVIEW  OF  TOOTH  NOMENCLATURE  21 

bucco-occlusal  point  angle  which  is   formed  by  the  meeting 

of  the  three  surfaces  named. 

The  gingival  point  angle  is  where  two  axial  surfaces  meet 
the  gingival  line.     Each  tooth  has  four  gingival  point  angles. 

The  angle  of  a  surface  is  where  two  of  its  margins  meet  at 
an  angle  and  are  named  by  combining  the  names  of  the  mar- 
gins so  meeting. 

To  Illustrate.  The  occlusal  surface  of  a  molar  has  four  sur- 
face angles,  namely  the  mesio-buccal,  mesio-lingual,  disto- 
buccal  and  disto-lingual. 

A  cusp  is  a  pronounced  eminence  on  the  occlusal  surface  of  a 
tooth  and  is  normally  present. 

A  slight  elevation  above  the  surrounding  surface  is  called  a 
tubercle,  and  is  generally  classed  as  an  abnormality. 

Ridges  are  elongated  elevations  on  the  surfaces  of  the  teeth 
and  are  named  according  to  their  location  or  shape,  as  mar- 
ginal ridge,  buccal  ridge  and  lingual  ridge,  these  being  ex- 
amples of  those  named  from  location. 

The  triangular  ridges  are  those  elevations  which  descend 
from  the  cusps  of  molars  and  bi-cuspids  towards  the  central 
portion  of  the  occlusal  surface  and  are  named  after  the  cusps 
of  which  they  are  a  part. 

A  transverse  ridge  is  formed  where  a  buccal  and  a  lingual 
triangular  ridge  join.  When  the  ridges  so  uniting  are  higher 
than  usual,  they  often  subdivide  the  central  fossa  of  the  lower 
molars  into  supplemental  fossa. 

A  fossa  is  a  rounded  or  angular  depression  on  the  surface  of 
a  tooth  and  are  most  common  on  the  occlusal  surfaces  of  the 
molars. 

A  groove  is  a  shallow  long-shaped  depression  in  a  tooth  sur- 
face. 

A  sulcus  is  a  long-shaped  and  pronounced  depression  in  a 
tooth  surface. 

A  sulcate  groove  is  formed  when  a  groove  follows  the  bot- 
tom of  a  sulcus. 


22  ESSENTIALS  OF  OPERATIVE  DENTISTRY 

A  fissure  is  where  the  plates  of  enamel  have  failed  to  unite 
in  the  process  of  development. 

The  developmental  grooves  are  fine  lines  of  depression  m 
the  surface  enamel  which  mark  the  junction  of  lobes  of  pn- 
marv  calcification. 


Figure  5.     A,  inter-proximal  space. 


The  inter-proximal  space  is  the  V-shaped  opening  between 
the  teeth  which  is  entered  in  going  gingival-wise  from  the 
contact  point  and  is  normally  filled  with  gum  tissue. 

The  inter-proximal  embrasures  are  those  widening  spaces 
entered  in  passing  from  contact  point  directly  to  the  buccal 
or  lingual.  As  the  buccal  embrasure,  lingual  embrasure  or 
labial  embrasure  when  applied  to  the  incisors. 


Figure  6.     A,  Buccal   embrasure.     Ai   Lingual   embrasure. 

The  pulp  chamber  is  that  space  in  the  crown  of  a  tooth 
normally  occupied  by  the  pulp. 


REVIEW  OF  TOOTH  NOMENCLATURE 


23 


The  pulp  canals  are  extensions  of  this  chamber  into  the  root 
Or  roots  of  a  tooth  and  each  canal  is  named  from  the  root  it 
occupies. 


Figure  7.     A,  Pulp  chamber.     B,  Pulp  canals.     C,  Horns  of  pulp. 


The  horns  of  a  pulp  are  the  sharpened  projections  of  the 
coronal  portion  of  the  pulp  in  molars  and  bi-cuspids,  extend- 
ing occlusaliy  toward  the  point  of  each  cusp.  In  mcisors  they 
extend  toward  each  angle. 


24 


ESSENTIALS  OF  OPERATIVE  DENTISTRY 


CHAPTER.  II. 
Review  of  Dental  Histology. 

Dental  histology  is  a  study  of  the  minute  structures  of  the 
teeth  and  adjacent  tissues. 

The  teeth  belong  to  the  dermal  skeleton  and  not  to  the  os- 
seous frame-work,  as  they  were  formerly  classified.  This 
is  made  conclusive  from  the  fact  that  the  first  evidence  of  tooth 
formation  is  seen  in  the  oral  epithelium.  However,  not  all 
of  the  tissues  of  a  tooth  are  epithelial  in  origin. 

The  tissues  of  which  a  tooth  is  made  up  are  enamel,  dentine, 
cementum  and  pulp. 


--i) 


Figure  8.     A,  Enamel.     B,  Dentine.     C,  Pulp.     D,  Cementum. 

The  enamel  only  is  derived  from  the  epithelium,  while  den- 
tine, cementum  and  pulp  are  formed  from  the  mesioblastic 
layer  of  tissue. 

The  dental  papilla  is  that  portion  of  follicle  which  is  enclosed 
in  the  epithelial  cup.  This  cup  later  becomes  the  enamel 
organ. 

The  pulp  is  what  remains  of  the  papilla  after  the  tooth  is 
fully  formed. 

The  cuticula  dentis  (or  Nasmyth's  membrane)  is  a  thin  cov- 
ering   found    on    recently    erupted    teeth,    soon    worn    away 


REVIEW  OF  DENTAL  HISTOLOGY 


26 


on  exposed  portions,  yet  persistent  for  months  and  even  years 
on  protected  portions.  It  is  probably  derived  from  the  outer 
tunic  of  the  enamel  organ. 

The  enamel  is  composed  of  from  three  and  one-half  to  six 
per  cent  water  and  from  ninety-four  to  ninety-six  and  one-half 
per  cent  inorganic  matter.  It  is  probable  that  the  "organic 
matter"  thought  to  be  obtained  aniletically  by  ignition  is  sim- 
ply water  in  combination  with  lime  salts. 

The  chief  constituents  of  enamel  are  phosphate  and  car- 
bonate of  calcium,  being  from  ninety  to  ninety-four  per  cent. 

The  structure  of  enamel  is  a  collection  of  five  and  six-sided 
rods  connected  by  means  of  a  cementing  substance. 

The  enamel  rods  are  generally  found  so  arranged  that  their 
long  axis  is  at  right  angles  to  the  surface  of  the  dentine  from 
which  they  arise,  particularly  so  in  the  middle  third  of  axial 
surfaces.  In  the  gingival  third  of  these  surfaces  there  is  an 
increasing  inclination  of  the  external  ends  of  the  enamel  rods 
towards  the  gingival.  The  same  is  true  of  the  inicsal  or 
occlusal  thirds  where  the  inclination  increases  as  the  cutting 
edge  is  approached. 


-A 

.p 


_--C* 


Figure  9.     A,   Enamel.     Rods   straight  and   of   easy   clevage.     B, 
Dento-enamel  junction.    C,  Dentine. 


26 


ESSENTIALS  OF  OPERATIVE  DENTISTRY 


The  rods  are  made  up  of  a  series  of  globules  placed  end  to 
end.  Under  a  powerful  microscope  they  resemble  a  string  of 
beads.    These  seem  to  be  joined  without  the  cemental  media. 

The  rods  differ  in  length.  While  most  of  the  rods  extend 
from  the  dentine  to  the  surface,  being  then  termed  full  length 
rods,  there  are  many  which  originate  in  the  body  of  the  enamel 
between  the  full  length  rods  and  continue  their  course  to  the 
surface.  As  the  rods  are  of  approximately  the  same  size  the 
additional  rods  would  seem  necessary  to  compensate  for  the 
difference  in  the  surface  area  of  the  dentine  and  enamel. 

In  some  there  will  occasionally  be  seen  a  rod  which  begins 
in  the  surface  of  the  dentine  and  falls  short  of  coming  to  the 
external  surface,  this  condition  being  most  frequently  met  with 
on  occlusal  surfaces  of  molars. 


Figure  10.     A,    Gnarled    enamel. 
junction.     D,  Fissure. 


B,    Dentine.      C,    Dento-enamel 


The  rods  vary  as  to  degree  of  curvature,  some  are  nearly 
straight,  some  describe  the  segment  of  a  circle,  while  others 
show  a  compound  curve  even  to  being  much  contorted  and 


REVIEW  OF  DENTAL  HISTOLOGY  27 

twisted.  Such  enamel  is  termed  "gnarled"  and  is  the  more 
resistant  to  stress  in  mastication  as  well  as  the  force  of  in- 
struments in  operative  procedures.  The  enamel  made  up  of 
straight  or  nearly  parallel  rods  is  the  more  friable  and  the 
easier  of  fracture  either  from  use  or  under  stress  of  instru- 
mentation. 

The  diameter  of  a  rod  varies  through  its  length,  resulting  in 
enlarged  sections  called  varicosities.  These  enlarged  portions 
of  one  rod  are  opposite  the  enlargements  of  the  rods  paralleling 
it,  which  condition  results  in  spaces  between  the  constricted 
portions  of  the  rods.  This  space  is  filled  with  a  highly  calci- 
fied cement  substance. 

The  interprismatic  cement  is  largely  composed  of  calcic  ma- 
terial, proved  by  the  fact  that  it  is  very  susceptible  to  the 
action  of  acids,  being  more  readily  dissolved  than  the  rods,  as 
in  the  process  of  decay  it  disappears  first  to  allow  the  rods 
to  fall  apart. 

The  cleavage  of  enamel  is  along  the  line  of  the  long  axis  of 
the  enamel  rods  accomplished  by  a  dissolution  of  the  cemental 
substance.  A  few  of  the  rods  may  be  broken  crosswise,  es- 
pecially near  the  point  of  impact  from  a  blow,  but  the  frac- 
ture is  never  to  any  great  extent  at  an  angle  to  the  direction 
of  the  long  axis  of  the  rods.  When  the  enamel  rods  rest  upon 
sound  dentine  and  each  is  supported  laterally  by  its  neighbors 
it  is  capable  of  resisting  a  great  amount  of  force,  but  when 
either  of  the  above  conditions  are  wanting  they  become  easily 
dislodged,  a  fact  of  great  moment  relative  to  the  making  of 
fillings. 

The  dentine  histologically  is  a  highly  developed  connective 
tissue,  which  is  non-vascular.  It  forms  the  greater  bulk  of  the 
tooth  which  it  materially  resembles  in  shape.  That  is  to  say 
if  the  enamel  which  covers  the  coronal  portion  and  the  ce- 
mentum  which  covers  the  root  portion  were  removed  there 
would  still  remain  the  general  characteristics  and  form  shown 
in  the  entire  tooth. 

The  physical  structure  of  dentine  is  that  of  a  partly  calcified 


28  ESSENTIALS  OF  OPERATIVE  DENTISTRY 

organic  matrix  traversed  by  a  system  of  tubules,  known  as  the 
dentinal  tubuli. 

The  matrix  is  seemingly  structureless,  and  composed  largely 
of  inorganic  matter.  As  it  is  physically  impossible  to  remove 
the  contents  of  the  tubules,  no  exact  chemical  analysis  has  as 
yet  been  made  of  the  matrix  proper. 

The  chemical  composition  of  dentine  as  a  whole,  is  given  as 
approximately  one-fourth  organic  and  three-fourths  inorganic, 
with  a  varying  amount  of  water  up  to  twelve  or  fourteen  per 
cent. 

The  principal  inorganic  substances  are  phosphate  and  fluor- 
ide of  calcium. 

The  tubules  are  minute  canals,  rounded  in  form,  which 
traverse  the  dentine  for  its  entire  thickness.  They  leave  the 
walls  of  the  pulp  chamber  at  right  angles  to  its  surface.  In 
their  course  to  the  surface  of  the  dentine  they  give  off  numer- 
ous branches  many  of  which  unite  with  the  neighboring  tu- 
bules. As  they  approach  the  surface  of  the  dentine  this  branch- 
ing increases  and  their  course  becomes  more  irregular.  As 
the  number  increases  they  become  more  closely  packed  at  the 
expense  of  the  matrix  for  the  size  of  the  tubules  show  slight 
variation. 

The  tubules  contain  a  substance  resembling  protoplasm 
which  is  connected  with  the  odontoblasts.  These  protoplasmic 
processes  are  known  as  dentinal  fibrils. 

The  dentinal  fibrils  are  the  media  through  which  sensation 
is  conveyed  to  the  pulp,  yet  it  has  not  been  demonstrated  that 
they  contain  nerve  filaments. 

The  dentinal  tubules  are  lined  with  a  particularly  indestruct- 
able  sheath  resisting  the  action  of  acids,  caustic  soda  and  even 
caries  of  the  teeth  does  not  destroy  them. 

The  odontoblasts  are  the  cells  which  perform  the  function 
of  forming  the  dentine  and  make  up  the  most  external  layer  of 
the  pulp. 

The  primary  dentine  is  that  which  normally  exists  in  a  fully 
formed  tooth.     When  the  tooth  is  fully  formed  the  odonto- 


REVIEW  OF  DENTAL  HISTOLOGY  29 

blasts  nearly  or  quite  cease  to  functionate  and  again  begin 
their  function  of  dentine  building  only  when  sufficiently  irri- 
tated to  result  in  a  stimulus. 


Figure  11.     A,  Carxious  cavity.     B,  Enamel.     C,  Primary  dentine. 
D,  Secondary  dentine.    E,  Pulp.     F,  Cementum. 

Secondary  dentine  is  the  term  applied  to  the  result  of  this 
renewed  functionating  of  the  odontoblasts. 

Cementum  is  the  external  portion  of  the  root  of  a  tooth  and 
acts  as  a  medium  of  attaching  the  pericementum  and  dentine. 
It  resembles  bone  both  anatomically  and  histologically  in 
many  respects.  Its  greatest  point  of  difference  is  the  ab- 
sence of  the  Haversian  system.  However,  there  are  present 
lacunae  and  canaliculi. 

The  formation  of  cementum.  Cementum  is  the  last  of  the 
dental  tissues  to  form,  covering  the  roots  of  young  teeth  but 
thinly.  Its  growth  persists  through  life,  so  that  the  teeth  in 
mature  life  show  a  considerable  body  of  cementum,  partic- 
ularly in  the  apical  region. 

When  this  growth  is  abnormal,  due  to  a  stimulating  irri- 
tant, it  is  termed  hypercementosis. 

The  cells  which  build  cementum  are  called  cementoblasts. 

The  tooth  pulp  is  the  soft  tissue  occupying  the  central  por- 
tion of  a  tooth  known  as  the  pulp  chamber.  It  is  the  forma- 
tive organ  of  the  dentine  during  the  process  of  development 
and  is  the  source  of  nutrition  to  the  dentine  during  life. 


30  ESSENTIALS  OF  OPERATIVE  DENTISTRY 

Anatomically  it  is  composed  of  a  very  delicate  connective 
tissue,  richly  supplied  with  blood  vessels  and  thickly  threaded 
with  nerve  fibers. 

The  blood  vessels  and  nerve  enter  the  pulp  through  the 
apical  foramen,  each  giving  ofif  many  branches  in  their  course 
to  the  periphery. 

The  most  external  cells  of  the  pulp  are  the  odontoblasts  and 
normally  have  no  sense  of  touch. 

The  shape  of  the  pulp  as  a  whole  resembles  that  of  the  ex- 
ternal surface  of  the  tooth  and  at  one  stage  of  development 
was  nearly  as  large.  But  during  the  formation  of  dentine  it 
really  incases  itself. 

The  process  of  retraction  on  the  part  of  the  pulp  seems  to 
take  place  more  slowly  from  near  the  seat  of  primary  calcifi- 
cation, resulting  in  horn-like  processes  projecting  into  the  den- 
tine in  the  direction  of  the  cusp  with  which  each  has  been  as- 
sociated in  developing.  As  these  horns  slowly  retract  they 
leave  what  is  termed  the  "line  of  retraction  of  the  pulp"  not 
always  vacated,  a  fact  which  has  to  be  borne  in  mind  when 
operating  in  these  localities. 

The  pericementum  (or  peridental  membrane)  is  a  fibrous 
connective  tissue  investing  the  root  of  the  tooth.  It  is  a  single 
membrane  common  to  the.cementum  and  alveolar  wall  thick- 
est in  the  apical  region  resulting  in  what  is  termed  the  apical 
space. 

The  functions  of  the  pericementum  are : 

First.     It  is  the  formative  organ  of  the  cementum. 

Second.  It  plays  a  large  part  in  the  retention  of  the  tooth  in 
its  socket,  aiding  it  to  resist  the  forces  of  traction,  tortion  and 
percussion. 

The  particular  arrangement  of  the  bundles  of  fibers  found  in 
the  pericementum  should  be  noted  as  they  materially  dififer  in 
their  direction. 

Arising  in  the  alveolus  some  of  the  fibers  pass  towards  the 
apex  and  others  towards  the  gingival  margin  some  distance 
before  being  attached  to  the  cementum,  while  others  pass  to 


REVIEW  OF  DENTAL  HISTOLOGY  31 

the  right  and  left  at  right  angles  to  the  long  axis  of  the  tooth 
before  being  also  attached  to  the  cementum. 

The  former  are  called  longitudinal  fibers  and  are  most 
abundant  near  the  apex  of  the  tooth,  while  the  latter  are 
called  the  circular  fibers  and  increase  in  number  as  the  gingival 
margin  is  approached.  At  the  gingival  some  of  the  fibers 
are  attached  to  the  gingivus  to  cause  the  gum  to  hug  the 
neck  of  the  tooth. 

It  will  be  seen  that  this  arrangement  admirably  assists  the 
tooth  to  withstand  the  strains  of  stress  to  which  it  must  fre- 
quenly  be  subjected. 

At  the  same  time,  it  permits  of  a  certain  amount  of  move- 
ment, thereby  protecting  it  from  the  effects  of  coming  in  con- 
tact with  unyielding  substances. 

Third.  It  furnishes  the  tooth  with  its  tactile  sense,  or  the 
sense  of  feeling,  that  its  possessor  may,  through  education, 
detect  the  substances  with  which  the  teeth  are  brought  in  con- 
tact. This  function  is  very  acute  at  all  times,  but  when  the 
pericementum  becomes  inflamed  this  property  becomes  ab- 
normally developed. 

Fourth.  The  pericementum  provides  nutrition  for  the  ce- 
mentum through  its  abundant  vascular  supply. 

The  cellullar  elements  of  the  pericementum  are :  Cemento- 
blasts,  persistent  in  the  formation  of  cementum.  Fibrablasts, 
for  the  repair  of  the  fibrous  tissues.  Osteoblasts,  situated  on 
the  side  next  to  osseous  tissues,  whose  function  is  to  build 
bone  around  the  fibers  of  the  pericementum,  to  thus  more 
strongly  attach  them  to  the  bony  wall.  Osteoclasts,  multi- 
nucliated  giant  cells,  not  always  present,  but  capable  of  acting 
upon  bone,  cementum  or  dentine  and  are  to  be  found  in  great 
numbers  when  the  dissolution  of  these  tissues  is  in  progress. 
Epithelial  cellular  bodies  are  not  infrequently  observed  in  the 
inner  portion  of  the  peridental  membrane.  Their  function  is 
not  known.  It  is  believed  by  some  that  they  are  the  remains 
of  the  enamel  organ. 


32  ESSENTIALS  OF  OPERATIVE  DENTISTRY 


CHAPTER     III. 

Instrument  Nomenclature. 

A  dental  instrument  is  an  appliance,  or  tool  by  means  ol 
which  a  dentist  performs  dental  operations.  It  is  quite  essen- 
tial that  we  learn  the  names  and  uses  of  the  instruments 
most  in  use  if  we  are  to  understand  the  teaching  of  operative 
procedures. 

Instruments  are  named  according  to  the  purpose  for  which 
they  are  intended,  where  and  how  used,  by  describing  their 
working  points  and  the  shape  of  their  shank. 

An  order  name  describes  that  for  which  an  instrument  is 
used,  as  for  example,  excavator,  clamps,  mallet,  pluggers,  bur- 
nishers, etc. 

A  sub-order  name  describes  where  or  how  an  instrument  of 
a  given  order  is  used  and  is  made  by  inserting  a  prefix  before 
the  order  name.  Examples,  hand  pluggers  push  or  pull  scalers, 
etc. 

A  class  name  describes  the  working  point  of  an  instrument. 
Examples,  serrated  plugger,  ball  burnisher,  chisel,  hatchet,  etc. 

A  sub-class  name  describes  the  shape  of  the  shank,  and  is 
made  by  prefixing  this  description  to  the  class  or  order  name 
or  to  both  combined.  Examples,  bayonet  plugger,  bin-angle 
chisel,  mon-angle  hatchet  excavator,  etc. 

Rights  and  lefts  are  made  as  further  divisions  of  many  of  the 
sub-classes  of  instruments  and  this  division  is  especially  ad- 
vantageous in  the  spoons,  bin-angle,  contra-angle  hatchets  and 
marginal  trimmers  as  it  enables  the  user  to  do  the  work  by  a 
movement  of  the  instrument  from  right  to  left  or  left  to  right, 
respectively. 

An  excavator  is  that  order  of  hand  instrument  used  in  the 
removal  of  tooth  substance  preparatory  to  the  making  of  a 
filling. 


INSTRUMENT  NOMENCLATURE  33 

A  chisel  is  that  class  of  excavator  which  has  the  cutting 
edge  placed  at  right  angles  to  the  shaft,  is  sharpened  by  grind- 
ing on  one  side  only  and  is  used  by  a  pushing  force  applied  in 
the  direction  of  the  long  axis  of  the  shaft. 

The  chisel  edge  is  made  with  a  bevel  at  an  angle  calculated 
to  plane  and  cleave  a  substance  possessed  of  a  grain,  and  so 
tempered  as  to  retain  an  edge  when  working  on  hard  sub- 
stances. 

The  use  of  the  chisel  is,  therefore,  the  cleaving  and  planing 
of  enamel.  The  planing  of  dentine  may  be  done  with  a  chisel 
or  with  other  instruments  of  a  similar  edge. 

Chisels  are  divided  into  sub-classes  according  to  the  shapes 
of  their  shanks,  as  straight,  bin-angle,  contra-angle,  etc. 

A  hoe  is  that  class  of  excavator  with  the  cutting  edge  at  a 
right  angle  with  the  shaft,  sharpened  on  the  distal  side  only 
and  is  used  by  a  pulling  force  applied  parallel  with  the  long 
axis  of  the  shaft. 

Hoes  are  divided  into  sub-classes  according  to  the  shape  of 
their  shanks,  as,  mon-angle,  bin-angle,  contra-angle  and  triple- 
angle  contra-angle.  The  hoe  is  used  mostly  for  cutting  den- 
tine. 

A  hatchet  is  that  class  of  excavator  with  the  line  of  the 
cutting  edge  laid  in  the  plane  parallel  with  the  long  axis  ol 
the  shaft. 

Hatchets  are  divided  into  sub-classes  the  same  as  the  hoes, 
accorfling  to  the  shape  of  their  shank,  as,  mon-angle,  bin-angle 
and  triple-angle  contra-angle.  The  hatchet  form  is  indispens- 
ible  for  the  construction  of  flat  walls  and  internal  surfaces, 
the  straightening  of  lines  and  the  sharpening  of  angles. 

A  gingival  marginal  trimmer  is  a  modified  hatchet. 

A  spoon  is  that  class  of  excavator  which  resembles  in  most 
respects  the  hatchet,  other  than  the  cutting  edge.  This  is 
sharpened  on  one  side  only  which  is  rounded  like  the  convex 
side  of  the  bowl  oi  a  spoon  from  which  it  derives  its  name.  The 
cutting  edge  is  rounded  and  sharpened  to  a  thin  edge.  They 
are  always  made  rights  and  lefts. 


34  ESSENTIALS  OF  OPERATIVE  DENTISTRY 

The  use  of  a  spoon  is  to  remove  foreign  matter  and  softened 
dentine  from  the  tooth  cavity. 

The  angles  between  the  shank  and  the  working  part  are 
designated  as  mon-angle,  bin-angles  and  triple-angles,  accord- 
ing to  the  number  of  angles  used  being  one,  two  or  three,  re- 
spectively. 

The  centra-angle  is  the  placing  of  such  angles  in  the  shank 
of  the  instrument  as  to  bring  the  cutting  edge  near  the  central 
line  of  the  shaft  which  removes  the  tendency  to  tip  or  turn 
in  the  hand  during  use. 

Bin-angles  and  triple-angles  are  properly  made  only  when 
contra-angled,  provided  the  cutting  edge  is  more  than  three 
millimeters  from  the  central  line  of  the  shaft. 

Formula  Names.  Some  instruments  have  the  formula 
stamped  on  the  handle  in  figures.  There  are  generally  three 
numbers  given.  The  first  is  the  width  of  the  blade  in  tenths 
of  a  millimeter.  The  second  is  the  length  of  the  blade  given 
in  millimeters.  The  third  is  the  angle  of  the  blade  with  its 
handle  given  in  the  hundredths  of  a  circle. 

When  a  four  number  formula  is  given,  as  with  gingival 
marginal  trimmers,  the  second  number  in  the  name  designates 
the  angle  of  the  cutting  edge  of  the  blade  with  shaft  or  handle. 
This  is  also  given  in  the  hundredths  of  a  circle. 

A  plugger  is  an  order  of  instrument  for  the  packing  of  metal 
in  the  making  of  a  filling.  Those  for  gold  are  serrated  on  the 
working  point  in  such  shape  as  to  result  in  a  surface  made  up 
of  prisms.  These  prisms  should  be  of  exactly  the  same  size 
on  all  the  points  used  in  any  individual  filling  when  pack- 
ing cohesive  gold,  as  the  interchange  of  points  of  differeni- 
sized  serrations  causes  bridging.  (See  manipulation  of  co- 
hesive gold.) 

The  dental  engine  is  almost  indispensable  and  when  properly 
used  is  a  blessing  to  our  patients  and  a  time-saver  to  the 
dentist.  However,  it  is  all  too  frequently  used,  especially  by 
students  and  young  practitioners,  to  do  things  which  can 
properly  be  done  only  with  the  hand  instruments.     The  mis- 


REVIEW  OF  DENTAL  HISTOLOGY  35 

use  of  the  dental  engine  has  caused  the  public  to  regard  it  as 
the  climax  of  all  pain-producing  instruments  in  the  dental 
office,  when  in  reality,  if  that  which  should  be  done  with  the 
engine  is  properly  done,  only  a  few  seconds  of  pain  is  induced 
in  the  preparation  of  a  very  severe  cavity. 

The  engine  bur  is  the  working  point  of  the  engine  and  is 
made  in  many  shapes  and  sizes.  However,  those  which  are 
round  and  inverted  cones,  whose  diameter  is  smaller  than  one 
millimeter,  are  most  frequently  indicated.  The  tendency  of 
the  beginner  is  to  use  too  large  .burs.  Burs  are  primarily 
intended  to  cut  dentine  in  outlining  cavity  walls,  and  under- 
mining enamel  to  facilitate  the  use  of  hand  instruments  and 
they  should  rarely  come  in  contact  with  the  enamel. 

The  most  indispensable  use  of  the  engine  is  for  the  polishing 
and  grinding  necessary  to  the  successful  termination  of  many 
varied  operations,  both  in  and  out  of  the  mouth. 

The  sharpening  of  instruments  is  of  the  utmost  importance 
and  is  by  no  means  accomplished  without  skill.  No  better  can 
a  dentist  execute  finished  work  than  can  a  tradesman  whose 
tools  must  be  keen  of  edge  if  he  is  to  produce  that  which  is 
worthy  of  his  craft.  Again,  dull  instruments  cause  an  undue 
amount  of  pain  at  each  attempt  to  cut,  where  as  when  sharp 
the  pain  is  less  and  the  efifort  in  cutting  is  materially  lessened, 
resulting  in  a  saving  of  time  and  energy  on  the  part  of  the 
dentist.  A  hard,  smooth  Arkansas  stone  is  the  onlv  suitable 
abradent  and  should  be  well  oiled  and  wiped  with  a  cloth 
after  each  use. 

As  the  instruments  are  shipped  to  the  dentist  they  are  usual- 
ly made  and  sharpened  especially  for  the  use  intended  and 
care  should  be  exercised  in  sharpening  that  the  degree  of 
angle  in  the  bevel  edges  is  not  changed. 

An  instrument  is  tested  for  sharpness  best  by  placing  the 
edge  with  light  pressure  against  the  finger  nail  and  attempting 
to  move  it  across  the  surface  at  right  angles  to  the  edge.  If 
it  catches  or  clings  to  the  nail  it  is  ready  for  use. 


PART  TWO. 


CHAPTER  IV. 

Cavity  Nomenclature. 

A  cavity  nomenclature  is  necessary  that  we  may  understand 
one  another  in  conversing  about  the  formation  of  cavities,  the 
description  of  their  several  parts  and  the  methods  of  procedure 
in  the  preparation  of  cavities  for  fillings. 

Cavities  derive  their  names  from  the  surfaces  of  the  teeth 
in  which  they  occur.  As  occlusal  cavity,  buccal  cavity,  labial 
cavity,  etc.,  being  cavities  occurring  in  the  surfaces  named. 

Proximal  cavities  are  those  occurring  in  the  proximal  sur- 
faces and  are  divided  into  two  classes,  namely,  mesial  and 
distal. 

A  simple  cavity  is  one  which  mvolves  but  one  surface. 
A  complex  cavity  is  one  which,  either  from  decay  or  ex- 
tension in  preparation,  involves  more  than  one  surface. 

Complex  cavities  are  named  by  combining  the  names  of  the 
surfaces  of  the  tooth  involved.  As  mesio-occlusal,  disto- 
occlusal,  mesio-disto-occlusal,  etc. 

An  axial  surface  cavity  is  one  which  occurs  in  an  axial  sur- 
face. 

Cavities  are  divided  as  to  their  origin  into  two  classes. 

First.  Pit  and  fissure  cavities,  which  are  those  originating 
in  the  minute  faults  in  the  enamel. 

Second.  Smooth  surface  cavities,  which  are  those  occur- 
ring on  surfaces  without  defects  in  the  enamel,  but  are  habit- 
ually unclean. 


CAVITY  NOMENCLATURE 


37 


Figure  12.  A,  Simple  axial  surface  cavity,  the  preparation  of 
which  would  develop  a  complex  cavity  by  involving  the  occlusal  sur- 
face.    B,  Simple  cavity.     C,  Complex  cavity. 


Cavities  are  grouped  according  to  similarity  in  line  of  treat- 
ment into  six  divisions. 

Class  I.  First.  Those  cavities  beginning  in  structural  de- 
fects.    (Pits  and  fissures.) 

Class  II.  Second.  Those  cavities  in  the  proximal  surfaces 
of  bi-cuspids  and  molars. 

Class  III.  Third.  Those  cavities  in  the  proximal  surfaces 
of  incisors  and  cuspids  not  involving  the  incisal  angle. 

Class  IV.  Fourth.  Those  cavities  in  the  proximal  surfaces 
of  incisors  and  cuspids  which  require  the  restoration  of  the 
incisal  angle. 

Class  V.  Fifth.  Those  cavities  in  the  gingival  third  of  the 
labial,  buccal  and  lingual  surfaces  not  originating  in  faults  in 
enamel.     (Pits  or  fissures.) 

Class  VI.     Sixth.     Abraded  surfaces. 

The  outside  walls  of  a  cavity  are  those  walls  faced  toward 
the  outside  surface  of  a  tooth  and  take  the  names  of  the  sur- 
faces of  the  tooth  toward  which  they  are  placed,  as  in  an 
occlusal  cavity  the  outside  walls  are  buccal,  distal,  mesial  and 
lingual,  while  the  fifth  or  internal  wall,  is  the  pulpal. 

The  pulpal  wall  is  that  inside  wall  of  a  cavity  which  is  to  the 
occlusal  of  a  pulp  and  in  a  plane  at  right  angles  to  the  long 
axis  of  the  tooth. 


38 


ESSENTIALS  OF  OPERATIVE  DENTISTRY 


A 


Figure  13.     A,  Cavity  class  1.    B,  Cavity  class  2.    F,  Cavity  class  6. 


Figure  14.    C,  Cavity  class  3.    D,  Cavity  class  4.    E,  Cavity  class  5. 


In  case  the  pulp  is  removed  the  pulpal  wall  becomes  the 
sub-pulpal  wall. 

The  axial  wall  is  the  inside  wall  of  an  axial  surface  cavity 
which  covers  the  pulp  and  in  a  plane  parallel  with  the  long 
axis  of  the  tooth. 

In  case  the  pulp  is  removed  in  an  axial  surface  cavity  the 
axial  wall  becomes  an  outside  wall  and  takes  the  name  of  the 
surface  of  the  tooth  toward  which  it  is  placed. 

The  gingival  wall  is  the  inside  wall  of  an  axial  surface  cavity 
placed  toward,  and  running  in  the  same  plane  as,  the  gingivae. 

Both  gingival  and  sub-pulpal  walls  may  be  present  in  cases 
of  pulp  removal  in  mesio-occlusal,  disto-occlusal  and  mesio- 


CAVITY  NOMENCLATURE 


39 


occlusal-distal  cavities  when  each  is  on  a  different  level  and 
the  individuality  of  each  wall  is  retained. 

The  inside  walls  of  a  cavity  are  those  faced  toward  the  pulp 
or  root  of  a  tooth. 

The  base  of  a  cavity,  or  seat  of  a  filling,  is  that  portion  of  a 
cavity  situated  at  right  angles  to  the  line  of  forces  to  which  it 
is  most  likely  to  be  subjected.  Generally  speaking,  this  is  the 
gingival  or  pulpal  wall  or  both,  where  these  walls  are  present, 
as  in  a  step  cavity. 


9 


O 


ill.,  ^-'z  ,,^ 


Figure  15.  Shows  an  axial  surface  cavity  in  mesial  of  molar, 
sectional,  mesio-distal  plane.  A,  Gingival  wall.  B,  Axial  wall.  C, 
Pulpal  wall.     D,  Distal. 


Figure  16.  Shows  an  axial  surface  cavity  Bucco-lingual  plane. 
A,  Buccal  wall.  B,  Lingual  wall.  C,  Pulpal  wall  and  base  of  cavity, 
or  seat  of  filling. 


40  ESSENTIALS  OF  OPERATIVE  DENTISTRY 

A  line  angle  is  formed  where  two  walls  of  a  cavity  meet 
along  a  line  and  is  named  by  joining  the  names  of  the  walls 
so  meeting. 

There  is  but  one  exception  to  this  rule.  That  is  where  the 
labial  and  lingual  walls  of  a  proximal  cavity  in  the  incisors  and 
cuspids  meet  along  a  line.  By  applying  the  rule  this  would 
be  called  the  labio-lingual  angle,  but  for  convenience  this  is 
named  the  "incisal  line  angle." 

A  point  angle  is  formed  where  three  walls  of  a  cavity  meet 
at  a  point  and  is  named  by  joining  the  names  of  the  walls  so 
meeting. 

There  is  but  one  exception  to  this  rule.  The  point  of  junc- 
tion of  the  axial,  labial  and  lingual  walls  in  proximal  cavities 
in  the  six  anterior  teeth  is,  for  convenience,  named  the  "in- 
cisal  angle." 

A  simple  cavity  has  two  sets  of  line  angles.  First,  the  in- 
ternal line  angles  surrounding  the  internal  wall,  which  is  the 
axial  wall  in  axial  surface  cavities,  and  the  pulpal  wall  in 
occlusal  cavities. 

The  second  set  external  line  angles  are  formed  by  the  junc- 
tion of  the  outside  walls  with  each  other. 

The  enamel  margin  is  that  point  on  the  surface  of  the  tooth 
where  the  cavity  begins  in  enamel. 

The  external  enamel  line  is  the  entire  outline  of  the  cavity 

at  its  enamel  margin. 

The  cavo-surface  angle  is  the  angle  formed  by  the  junction 
of  the  wall  of  the  cavity  with  the  external  surface  of  the  tooth. 

The  base  of  the  cavo-surface  angle  is  the  external  enamel 
surface. 

The  marginal  bevel  of  a  cavity  is  the  deflection  of  a  cavity 
wall  from  its  established  plane,  near  the  external  enamel  line. 

It  is  necessary  that  beveling  be  resorted  to  in  order  to  man- 
age the  enamel  margins,  direct  the  external  enamel  line  and 
control  the  degree  of  the  cavo-surface  angle  without  disturbing 
the  general  retentive  form  of  the  cavity. 


CAVITY  NOMENCLATURE 


41 


The  bevel  angle  is  the  angle  formed  by  the  junction  of  the 
marginal  bevel  with  the  remaining  portion  of  the  wall  of  which 
it  is  a  part. 

The  base  of  the  bevel  angle  is  the  remaining  portion  of  the 
cavity  wall. 


^'  •»  i-'As;.i\iSi''' 


Figure  17.  A,  External  enamel  surface.  B,  Cavo-surface  angle 
C,  Marginal  bevel.  D,  Bevel  angel.  E,  Enamel  wall.  F,  Dento- 
enamel   junction.     G,  Dentinal   wall.     H,  Base   line  angles. 


The  bevel  angle  is  covered  when  tlie  filling  is  in  position. 
Its  distance  from  the  enamel  margin  depends  upon  the  filling 
material  used,  the  direction  the  surface  of  the  filling  runs  from 
the  margin  and  the  location   in  the  cavity  outline.     To  illus- 


42  ESSENTIALS  OF  OPERATIVE  DENTISTRY 

trate :  With  porcelain  inlays  and  amalgam  the  bevel  angle 
must  be  deeply  buried,  which  means  a  long  bevel  or  more  dis- 
tance between  the  cavo-surface  angle  and  the  bevel  angle, 
where  as  with  cast  gold  inlays  and  platinum  combination 
fillings  the  bevel  angle  should  be  near  the  surface,  resulting 
in  a  short  marginal  bevel.  The  distance  of  the  bevel  angle 
from  the  cavo-surface  angle  must  not  afifect  the  degree  of  the 
latter  angle  but  determines  only  the  length  of  the  bevel  and 
the  thickness  of  the  filling  at  its  margin. 

The  planes  of  a  tooth  are  three  :n  number :  Horizontal  plane, 
mesio-distal  plane  and  bucco-lingual  plane. 

The  horizontal  plane  is  at  right  angles  to  the  long  axis  of 
the  tooth. 

The  mesio-distal  plane  passes  through  the  tooth  from  mesial 
to  distal  parrallel  with  the  long  axis. 

The  bucco-lingual  plane  passes  through  the  tooth  from 
buccal  to  lingual  parallel  with  the  long  axis  of  the  tooth.  In 
the  six  anterior  teeth  this  plane  would  be  labio-lingual. 


CAVITY   PREPARATION  43 


CHAPTER   V. 

Cavity  Preparation.  (General  Considerations.) 
Definition  of  Cavity  Preparation.  Cavity  preparation  is  that 
term  applied  to  those  mechanical  procedures  upon  a  tooth, 
looking  to  the  making  of  a  filling,  as  well  as  those  changes 
and  extensions  necessary  to  resist  stress  and  prevent  a  re- 
currence of  decay. 

A  completed  cavity  should  be  a  combination  of  flat  walls 
coming  together  at  definite  angles,  surrounded  by  an  external 
line  made  up  of  the  largest  curves  permissible. 

The  line  angles  within  a  cavity,  which  are  a  necessary  part 
of  resistance  and  retention  forms,  should  never  be  permitted 
to  end  in  the  external  enamel  line. 

,  A  Review. 

Cavities  are  divided  as  to  origin,  into  pits  and  fissures,  and 
smooth  surface  cavities. 

Pit  and  fissure  cavities  are  those  wherein  the  location  of  pri- 
mary attack  is  in  the  faults  in  enamel,  which  defect  is  a  pre- 
disposing cause. 

The  location  of  such  defects  mark  the  points  and  lines  of 
union  of  the  various  fields  of  enamel  calcification  in  their  ex- 
tension from  the  primary  centers  of  development,  and  are 
most  frequently  found  on  the  occlusial  surface  of  molars  and 
bi-cuspids.  They  are  occasionally  met  with  on  the  buccal 
surface  of  lower  molars,  and  the  lingual  surface  of  upper 
molars  and  incisors. 

Smooth  surface  cavities  are  those  occurring  on  the  smooth 
surfaces  of  teeth  which  are  habitually  unclean.  The  predis- 
posing cause  being  the  tooth's  environment  which  favors  the 
accumulation  and  retention  of  the  exciting  cause  of  caries. 


44  ESSENTIALS  OP  OPERATIVE  DENTISTRY 

In  this  division  of  caries  it  will  be  seen  that  the  exciting 
cause  is  the  same,  namely,  the  acids  of  fermentation,  while 
the  predisposing  cause  in  one,  is  intrinsic  faults  in  the  tooth's 
structure.  With  the  other  it  is  entirely  a  matter  of  environ- 
ment. 

Classification  as  to  methods  of  management  is  of  advantage 
to  facilitate  description  in  treatment,  and  are  here  repeated 
as  given  in  Chapter  IV. 

Class  One.     Pit  and  fissure. 

Class  Two.  Cavities  in  proximal  surfaces  of  molars  and  bi- 
cuspids. 

Class  Three.  Cavities  in  proximal  surfaces  of  incisors  and 
cuspids  not  involving  the  incisal  angle. 

Class  Four.  Cavities  in  proximal  surfaces  of  incisors  and 
cuspids  which  require  the  restoration  of  the  incisal  angle. 

Class  Five.  Those  cavities  in  the  gingival  third  of  the 
labial,  buccal  and  lingual  surfaces  not  originating  in  faults  in 
enamel. 

Class  Six.     Abraded  surfaces. 

Modification  of  form  is  necessary  in  cavity  preparation  to 
meet  the  various  properties  of  the  different  filling  materials 
used.  This  is  particularly  true  when  considering  the  differ- 
ence in  edge  strength  and  flow  of  the  different  fillings  used. 
This  will  be  more  fully  considered  in  following  chapters. 

The  selection  of  a  filling  material  should  involve  a  considera- 
tion of  the  following  points :  The  character  of  the  teeth  and 
oral  fluids,  the  evident  care  bestowed  upon  the  teeth,  condi- 
tion of  patient's  health,  sex,  age  of  patient  and  the  life  ex- 
pectancy of  the  patient  and  of  the  individual  teeth. 

Order  of  Procedure.  To  simplify  the  preparation  of  all 
cavities  and  to  insure  the  observance  of  certain  fundamental 
principles  it  is  well  to  follow  a  definite  order  of  procedure. 
This  will  greatly  facilitate  the  operations  of  the  student  and 
lead  to  the  establishment  of  habits  by  the  practitioner  which 
will  stand  for  thorougfh  methods  of  execution. 


CAVITY  PREPARATION  45 

The  following  would  seem  to  be  the  natural  order : 

First.     Gain  access. 

Second.     Outline  form. 

Third.     Resistance  form. 

Fourth.     Retention  form. 

Fifth.     Convenience   form. 

Sixth.     Removal  of  remaining  decay. 

Seventh.     Finishing  of  enamel  walls. 

Eighth.     Toilet  of  the  cavity. 

In  some  cases  it  will  be  found  advisable  to  place  the  sixth 
order  as  third. 

"Extension  for  Prevention"  is  a  phrase  applied  to  the  ex- 
tending of  cavity  margins  upon  smooth,  unclean  surfaces, 
from  an  area  of  great  liability  to  caries,  to  an  area  of  lesser 
liability  and  applies  only  when  the  extension  of  margins  is 
made  necessary  solely  for  the  purpose  of  preventing  a  recur- 
rence of  decay.  This  will  be  more  fully  discussed  in  the  chap- 
ter on  outline  form. 

Affected  dentine  is  dentine  which  has  been  acted  upon  by 
the  lactic  acid  in  advance  of  the  micro-organisms  of  caries. 

Infected  dentine  is  dentine  which  has  been  penetrated  by 
micro-organisms  of  caries. 

Objects  in  Filling  Teeth.  There  are  four  general  objects  in 
view  in  the  filling  of  teeth  : 

First.     To  arrest  the  loss  of  tooth  substance. 
Second.     To  prevent  recurrence  of  caries. 

Third.     To  restore  full  tooth  contour. 

Fourth.  To  improve  the  primary  conditions  as  to  the  per- 
formance of  function  and  cosmetic  effects. 


46  ESSENTIALS  OP  OPERATIVE  DENTISTRY 


CHAPTER     VI. 

Gaining  Access  (In  Cavity  Preparation.) 

Definition,  Gaining  access  is  the  term  applied  to  those  pro- 
cedures necessary  to  make  sufficient  room  for  the  proper  intro- 
duction of  the  filling. 

Sufficient  access  is  important,  that  we  may  have  the  advant- 
age of  space  to  properly  handle  the  instruments  and  appli- 
ances used  in  the  procedures  of  making  a  filling,  that  we  may 
be  able  to  properly  introduce  the  filling  to  the  cavity,  that 
there  may  be  complete  contour  restoration  of  tooth  form  ana 
that  the  desired  contact  relation  may  be  established  to  the 
adjacent  tooth. 

Access  to  the  tooth  is  the  first  consideration  and  will  m- 
volve  the  opening  of  the  mouth  to  a  sufficient  degree  to  permit 
of  the  free  use  of  the  usual  appliances.  The  proximal  spaces 
used  for  the  adjustment  of  the  dam  should  be  examined  to 
make  sure  that  the  rubber  and  ligatures  will  pass  to  the 
gingival  line  without  injury.  A  sufficient  number  of  teeth 
should  be  isolated,  say  four  or  five  (See  Chapter  XV)  to  give 
a  clear  and  unobstructed  view  of  the  cavity  and  surrounding 
teeth. 

Access  to  the  Cavity  is  imperative.  The  operator  must  be 
able  to  bring  the  cavity  into  full  view.  Cases  where  there  has 
been  considerable  decay  sub-gingivally,  and  no  recession  ol 
the  gum  tissue,  or  as  will  be  frequently  met  with,  a  tumi- 
faction  of  the  gum  septa,  proper  access  will  involve  the  pack- 
ing of  the  cavity  with  a  tampon  of  cotton  which  has  been 
dipped  in  chlora-percha,  or  a  packing  of  gutta-percha,  for  a 
period  of  twenty-four  or  forty-eight  hours,  to  crowd  the  en- 
croaching gum  tissue  from  the  cavity.  A  neglect  of  this  con- 
sideration  of  access   will   many   times   make  proper   manage- 


GAINING  ACCESS   (In  Cavity  Preparation)  47 

ment  of  the  gingival  wall  and  margin   most  difficult  or   im- 
possible. 

Surgical  access  may  be  practiced  on  the  cavity  margins, 
w^hen  all  tooth  structure  thus  removed  will  subsequently  be  re- 
placed with  filling  material.  It  may  be  practiced  on  the  gum 
septa  when  there  has  been  excessive  tumifaction  in  the  proxi- 
mal space. 

Formerly  it  has  been  practiced  in  gingival  third  cavi- 
ties where  the  decay  was  to  a  marked  extent  subgingival, 
and  it  was  desired  to  make  a  cohesive  gold  filling.  How- 
ever, much  of  this  questionable  practice  may  now  be  avoided 
by  the  use  of  the  gold  inlay,  made  from  the  wax  model  as  the 
presence  of  the  over  lying  gum  is  no  considerable  hinderance 

Access  as  Related  to  Restoration  of  Proximal  Space.  As 
tooth  substance  is  lost  through  decay  in  proximal  cavities, 
there  is  in  most  cases  a  movement  of  the  teeth  to  the  proxi- 
mal, thus  encroaching  on  the  normal  space,  which  robs  the 
gums  of  sufficient  room  for  full  festoon  and  makes  it  wholly 
impossible  for  the  operator  in  making  a  filling  to  restore  the 
tooth  contour,  and  leave  a  normal  amount  of  room  for  the 
rehabitation  of  the  gum  septa.  The  surfaces  of  a  tooth  which 
are  covered  with  healthy  gum  tissue  are  practically  immune 
from  both  primary  and  secondary  caries,  and  it  is  of  great 
advantage  to  a  filling  the  outline  of  which  in  the  proximal 
gingival  third  is  so  protected.  Good  access  should  be  gained 
by  preliminary  separation  so  that  when  the  completed  filling 
with  its  full  tooth  form  restoration,  is  in  place  there  is  re- 
stored the  normal  space  in  the  proximal  for  the  habitation  of 
a  normal  gum  septa. 

A  failure  to  regard  this  fact  will  result  in  a  strangulated,  dis- 
eased and  dwarfed  septa,  inviting  an  accumulation  of  the  ene- 
my of  tooth  structure  and  an  early  loss  of  the  filling  through 
secondary  caries. 

Preliminary  separation  of  the  teeth  in  proximal  filling  is, 
therefore,  necessary  in  most  cases  to  make  possible  the  restora- 
tion of  tooth  form,  to  restore  the  normal  proximal  space  that 


48  ESSENTIALS  OF  OPERATIVE  DENTISTRY 

a  normal  gum  septa  may  result  and  to  make  the  ideal  con- 
tact with  the  adjoining  tooth. 

Restoration  of  tooth  form  is  essential  that  the  full  function. 
of  the  masticating  organs  may  be  established  and  maintained. 
It  is  also  desirable  for  cosmetic  reasons,  as  the  more  nearly 
a  dentist  approaches  complete  tooth  contour  restoration,  with 
all  of  its  details,  the  more  pleasing  is  the  appearance  and  the 
more   artistic  the  result. 

Proper  contact  point  is  many  times  impossible  unless  suffi- 
cient access  has  been  secured  through  preliminary  separation. 
This  contacting  should  be  a  point  of  contact,  the  embrasures 
widening  therefrom  in  every  direction.  It  should  be  in  no 
sense  a  line  of  contact  nor  a  surface,  no  matter  how  small.  It 
is  advisable  many  times,  in  this  respect,  to  improve  on  nature 
by  slightly  varying  the  surface  of  the  filling  from  the  original 
shape  of  the  tooth,  as  many  times  the  predisposing  cause  of 
the  primary  decay  has  been  defective  contact  or  flattened 
tooth  surface. 

The  saving  of  tooth  substance  is  materially  effected  by  ac- 
cess through  preliminary  separation,  particularly  in  the  plac- 
ing of  inlays,  as  the  more  thoroughly  this  first  step  in  pro- 
cedure has  been  accomplished  the  less  cutting  will  be  required 
for  convenience  form,  a  point  of  no  small  importance. 

Methods  of  Separation.  There  are  two  classifications  of 
separation  to  gain  access.  Preliminary,  which  is  also  slow 
separation,  and  immediate,  which  is  rapid,  both  of  which  are 
a  part  of  gaining  access. 

The  preliminary  is  a  part  of  the  first  consideration  while 
immediate  separation  is  brought  to  our  attention  during  the  in- 
troduction of  the  filling. 

Preliminary  separation  is  best  accomplished  in  proximal 
cavities  in  bi-cuspids  and  molars,  (Class  II)  by  packing  into 
the  partially  excavated  cavity  an  excess  amount  of  gutta- 
percha base  plate.  A  few  days  or  in  some  instances  a  few 
weeks  will  suffice  to  accomplish  the  desired  result,  particularly 
if  the  patient  uses  that  location  in  the  mouth  for  daily  masti- 
cation of  solid  food. 


GAINING  ACCESS   (In  Cavity  Preparation)  49 

In  the  proximal  space  in  the  six  anteriors  preliminary  sepa- 
ration is  best  accomplished  by  the  use  of  cotton  tampons 
tightl)-  packed  in  the  cavity  and  ligatured  securely  to  position. 

Avoid  gum  injuries  in  the  use  of  elastic  rubber.  In  the  use 
of  the  methods  gi\en  care  should  be  used  not  to  crowd  the  gum 
tissue  as  permanent  injury  may  result. 

There  are  other  materials  used  in  slow  separation,  as  linen 
tape,  wooden  wedges,  etc.,  each  with  their  merit  and  indicated 
uses. 

Immediate  separation  is  best  accomplished  with  the  mechan- 
ical separator,  and  should  be  used  to  gain  additional  access, 
not  already  secured  by  preliminary  separation,  or  may  be 
used  primarily  when  only  a  small  amount  of  additional  space 
is  desired.  This  instrument  should  be  adjusted  as  soon  as 
convenient  after  securing  outline  form,  and  removed  only 
when  the  filling  is  finished. 

Soreness  resulting  from  tooth  separation  should  be  treated 
as  any  case  of  acute  pericementitis,  by  giving  the  tooth  phy- 
siological rest,  and  the  use  of  stimulating  applications  on  the 
gum  over  the  tooth's  root. 


(3) 


50  ESSENTIALS  OP  OPERATIVE  DENTISTRY 


CHAPTER     VII. 

Outline  Form. 

Definition.  Outline  form  is  that  part  of  cavity  preparation 
which  determines  the  area  of  the  tooth  surface  to  be  included 
within  the  external  enamel  line. 

Extend  to  Sound  Enamel.  All  cavity  margins  should  be 
extended  until  all  indications  of  surface  decay  has  been  in- 
cluded. 

Obtain  Full  Length  Rods.  If  necessary,  further  extend  the 
outline  until  full  length  enamel  rods,  supported  by  sound  den- 
tine, has  been  reached. 

Self-Cleansing  Margins.  Extend  the  cavity  outline  until 
the  surface  of  the  filling  can  be  so  formed  that  the  enamel  mar- 
gin not  protected  by  the  gum  will  be  mechanically  cleansed  by 
the  excursions  of  food  in  mastication. 

In  Relation  to  Developmental  Grooves.  A  cavity  outline 
should  not  follow  a  developmental  groove  or  parallel  it  so 
closely  as  to  leave  a  small  strip  of  intervening  enamel.  The 
outline  should  cross  the  grooves  as  squarely  as  possible. 

Fissures  and  Sulcate  Grooves.  All  fissures,  sulcate  grooves 
and  angular  developmental  grooves  encountered,  should  be 
included  within  the  cavity  outline.  This  comes  in  for  the 
greatest  consideration  when  part  of  the  outline  is  laid  on  the 
occlusial  surface  of  molars  and  bi-cuspids. 

Enamel  Eminences.  The  outline  should  avoid  extreme  emi- 
nences of  enamel  and  centers  of  primary  development.  Such 
locations  are  subject  to  the  extremes  of  stress,  during  masti- 
cation. When  the  eminence  in  question  is  the  seat  of  primary 
calcification  it  will  be  found  to  be  less  perfect  in  formation 
than  the  portion  midway  from  this  point  to  the  grooves. 

Avoid  Angles  in  Outline. — The  outline  should  be  made  up 
of  the  greatest  curves  possible,  avoiding  all  angles.     Nearly 


OUTLINE  FORM  51 

flat  walls  as  found  on  axial  surfaces  should  show  nearly 
straight  lines  or  the  segments  of  very  large  circles,  while  on 
occlusal  surfaces,  which  are  made  up  of  a  succession  of  de- 
pressions and  eminences,  the  outline  will  show  a  combina- 
tion of  smaller  curves. 

Outline  in  the  Embrasures.  The  outline  in  the  labial,  buccal 
and  lingual  embrasures  should  be  parallel  to  each  other  and 
at  right  angles  to  the  seat  of  the  cavity,  and  pass  under  the 
free  margin  of  the  gum  at  a  point  in  full  view  of  the  operator. 

Enamel  Margins.  The  enamel  margins  should  be  planed 
smooth  to  a  full  cleavage  of  the  enamel  rods  and  then  slightly 
beveled  that  the  rods  at  the  cavo-surface  angle  may  be  full 
length  rods,  supported  by  shortened  enamel  rods  which  arc 
protected  by  the  overlying  filling  material. 

Extension  for  prevention  is  a  term  applied  to  that  procedure 
which  has  for  its  object  only,  the  carrying  of  the  cavity  out- 
line upon  smooth,  unclean  surfaces,  from  an  area  of  great 
liability  to  caries  to  an  area  of  lesser  liability. 

This  has  reference  to  caries  of  enamel  only  and  will  come 
into  consideration  in  cavity  outline  when  the  rules  previously 
given  have  not  carried  the  outline  to  comparatively  safe  and 
immune  localities. 

Extension  for  prevention  does  not  mean  the  consideration 
of  resistance  to  stress.  It  bears  no  reference  to  decay  of  the 
dentine.     It  has  no  relation  to  the  management  of  frail  walls. 

Its  maximum  application  is  found  in  the  management  of 
small  cavities  where  the  ravages  of  decay  have  not  yet  car- 
ried the  outline  of  the  cavity  to  areas  not  subject  to  primary 
enamel  dissolution. 

The  abuses  of  extension  for  prevention  result  in  much  un- 
necessary loss  of  tooth  substance,  while  its  sane  and  legitimate 
use  is  one  of  the  most  important  factors  in  tooth  salvage. 

Extension  for  resistance  is  a  term  applied  to  that  procedure 
which  has  for  its  sole  object  the  carrying  of  the  cavity  outline 
from  localities  subjected  to  great  stress,  to  localities  not  fre- 
quently subjected  to  the  crushing  strain.     This  is  often  times 


52  ESSENTIALS  OF  OPERATIVE  DENTISTRY 

mistaken  for  extension  for  prevention,  where  as  it  has  refer- 
ence only  to  resistance  to  stress. 

A  proper  application  of  this  procedure  will  involve  a  care- 
ful study  of  occlusion  and  articulation  in  each  individual 
case. 

Dangers  of  Increased  Cavity  Outline.  The  danger  of  sec- 
ondary caries  increases  in  each  mouth  proportionately  as  the 
aggregate  length  of  cavity  outline  is  increased. 

To  Illustrate.  If  the  total  length  of  cavity  outline  of  all 
fillings  in  a  mouth  is  doubled  by  the  increase  in  number  of 
fillings  the  liability  to  secondary  caries  is  doubled,  all  else 
being  equal.  For  that  reason  each  individual  cavity  should 
have  its  outline  as  short  as  permissible. 

The  laying  of  cavity  outline  in  locations  not  susceptible  to 
primary  caries  will  materially  decrease  the  liability  to  recur- 
rent decay,  even  though  the  aggregate  cavity  outline  in  the 
mouth  is  thereby  greatly  lengthened.  An  aggregate  cavity 
outline  of  two  feet  is  preferable  to  a  total  of  one  foot,  provided 
the  additional  length  has  been  caused  to  extend  to  locations 
not  liable  to  caries. 


RESISTANCE  FORM  5P. 


CHAPTER    VIII. 
Resistance  Form. 

Definition.  Resistance  form  is  the  term  applied  to  that  por- 
tion of  cavity  preparation  which  deals  with  the  consideration 
of  the  resistance  to  crushing  strain. 

Resistance  form  involves  a  consideration  of  the  management 
of  weakened  enamel  walls,  the  flattening  of  the  seats  of  fill- 
ings, the  extending  of  margins  from  localities  of  great  liability 
to  stress  to  localities  of  lesser  liability  to  stress  (extension  for 
resistance)  and  a  study  of  the  flow  and  edge  strength  of  the 
filling  material  used  with  a  view  of  so  shaping  the  cavity  as 
to  minimize  the  effects  of  crushing  strain. 

Its  importance  is  in  direct  proportion  to  the  exposure  of  the 
filling  in  occlusion  and  articulation,  and  the  strength  of  the 
closure  of  the  jaws. 

The  force  to  provide  for  is  from  one  to  two  hundred  pounds 
and  in  some  cases  even  more,  particularly  in  mid-jaw  locations. 

Weakened  enamel  walls  are  those  which  through  decay,  or 
unnecessary  cutting,  have  been  robbed  of  much  of  their  sup- 
porting dentine.  All  such  unsupported  enamel  should  be  cut 
away  with  a  chisel,  particularly  if  by  any  chance  the  wall  of 
enamel  under  consideration  will  receive  much  stress  in  pro- 
cess of  mastication. 

Stress  from  vdthin  should  be  avoided  by  not  allowing  such 
weakened  walls  to  remain  and  form  any  part  of  the  retention 
of  the  filling. 

Weakened  walls  are  sometimes  allowed  to  remain,  or  a  por- 
tion of  them,  when  they  can  be  so  protected  by  a  layer  of  rigid 
filling  material  as  to  prevent  all  stress,  permissible  only  when 
their  presence  will  screen  unsightly  metal  fillings  and  when 
the  kind  of  filling  used  can  be  introduced  without  injury 
there   to. 


54  ESSENTIALS  OF  OPERATIVE  DENTISTRY 

Flat  seats  for  fillings  is  imperative  in  resistance  form  as 
applied  to  stress.  Seats  should  be  cut  at  right  angles  with  the 
direction  of  the  stress  of  mastication,  which  is  usually  at  right 
angles  with  the  long  axis  of  the  tooth. 

As  Examples.  In  occlusal  cavities  the  pulpal  wall  should 
be  cut  flat,  and  all  of  the  surrounding  walls  meet  it  at  definite 
angles. 

In  proximo'-occlusal  cavities,  where  maximum  resistance 
form  is  needed,  the  gingival  wall  should  be  cut  flat  in  the  hori- 
zontal plane  with  the  surrounding  walls  meeting  it  at  definite 
angles.  The  step  is  also  given  a  horizontal  seat  in  the  same 
plane. 

The  Step  as  a  Part  of  Resistance  Form.  The  addition  of 
the  step  in  cavities,  Class  II  and  Class  IV,  is  for  the  purpose 
of  giving  added  resistance  form  as  well  as  retention  form.  By 
this  procedure  in  proximal  cavities  in  bi-cuspids  and  molars, 
the  stress  upon  buccal  and  lingual  walls  of  the  cavity  proper 
is  transferred  to  those  portions  of  the  same  walls  which  are  a 
part  of  the  step,  a  location  much  better  situated  to  withstand 
the  tipping  strain.  In  cavities.  Class  IV,  the  addition  of  the 
step  on  incisal  or  lingual  or  both,  will  give  added  resistance 
form,  avoiding  heavy  cutting  at  the  angle  which  usually 
weakens  the  remaining  tooth  substance  at  the  angle,  to  say 
nothing  of  the  dangers  of  crossing  the  retractive  tract  of  the 
pulp  in  this  location. 

Extension  of  Margins.  The  extending  of  margins  which 
would  otherwise  be  subject  to  great  and  frequent  stress  is 
most  essential.  Before  applying  the  rubber  dam  each  case 
should  be  inspected  for  the  surfaces  contacted  in  occlusion 
and  articulation,  and  then  the  margin  so  laid  as  to  occupy  the 
less  exposed  positions.  Many  times  stress  can  not  be  wholly 
avoided,  but  the  subject  should  receive  due  consideration  and 
good  judgment  exercised. 

Properties  of  Filling  Material.  With  resistance  form  must 
be  considered  the  properties  of  the  filling  material  to  occupy 
each  individual  cavity.  The  greater  the  amount  of  flow  in 
a  filling  material  the  greater  will  be  the  internal  stress  upon 


RETENTION  FORM  55 

weak  walls,  hence  the  maximum  consideration  of  resistance 
form  will  be  found  in  the  use  of  amalgam. 

The  greater  the  edge  strength  of  a  filling  material,  the  more 
protection  will  it  give  cavity  margins,  yet  resistance  form 
should  receive  scarcely  less  consideration  with  those  fill- 
ings of  maximum  edge  strength. 

The  extent  of  marginal  extension  for  resistance  form  will 
be  less  with  cohesive  gold  and  gold  inlays  than  with  other 
forms  of  fillings. 


CHAPTER   IX. 
Retention  Form, 


Definition.  Retention  form  is  that  part  of  the  procedure  in 
cavity  preparation  which  deals  with  the  provisions  for  pre- 
venting the  filling  from  being  displaced  by  force.  Force  is 
one  of  the  greatest  enemies  to  permanency  in  tooth  filling, 
second  only  to  recurrent  caries. 

Partially  Provided  For  in  Resistance  Form.  Retention  form 
is  partially  provided  for  in  the  previous  step  of  resistance  form, 
but  it  is  further  necessary  that  provision  be  made  to  resist  the 
force  of  mastication  in  order  to  prevent  the  filling  as  a  whole 
from  being  moved  from  its  seat. 

Maximum  retention  form  is  required  in  cavities  in  the  prox- 
imal surfaces  of  bicuspids  and  molars,  (Class  II)  as  the 
missing  proximal  wall  renders  these  fillings  particularly  ex- 
posed to  the  lateral,  or  tipping  force,  during  the  movements 
of  the  mandible. 

Maximum  retention  form  is  not  required  when  making  a 
simple  cavity,  as  such  are  protected  from  the  dangers  oi 
lateral  strain  by  the  presence  of  all  surrounding  external  walls. 
This  will  be  found  to  be  the  case  in  cavities,  Class  I,  III  and 
V,  when  occlusion  is  normal.  While  in  cavities  Class  II,  IV 
and  VI,  much  additional  cutting  is  sometimes  necessary  to 
give  ample  retention    form. 


56  ESSENTIALS  OP  OPERATIVE  DENTISTRY 

The  stepping  of  a  cavity  is  for  both  resistance  and  retention 
forms  and  should  be  varied  to  meet  the  requirements  in  each 
individual  case. 

Flat  seats  for  all  fillings  is  an  expedient  of  resistance  form 
and  should  be  laid,  as  previously  stated,  in  a  plane  at  right 
angles  to  the  stress  of  mastication. 

Acute  Angles  Required.  Aluch  of  the  retention  form  re- 
quired is  gained  by  la3nng  the  external  surrounding  walls  at 
an  angle  slightly  acute  to  the  seat  of  the  cavity. 

This  has  been  termed  under-cutting,  but  the  term  is  aban- 
doned for  fear  that  some  might  confuse  the  method  above 
referred  to  with  a  now  entirely  obsolete  practice  of  creating 
retention  by  the  use  of  pits  and  grooves  laid  in  the  dentinal 
walls. 

Little  Resistance  in  Enamel.  It  should  be  remembered  in 
this  step  in  the  procedure  of  cavity  preparation  that  there 
is  very  little  resistance  to  force,  in  a  filling  wherein  this  re- 
tention form  is  provided  for  in  enamel  walls.  The  enamel  is 
removed  to  a  depth  sufficient  to  get  anchorage  in  angles  laid 
in  dentine.  A  good  idea  of  the  amount  of  the  retention  form 
possessed  by  any  completed  cavity  may  be  gained  if  one 
will  for  the  time  being  imagine  that  all  enamel  has  been 
removed  from  the  tooth.  The  remaining  cavity  will  still 
have  nearly  the  original  amount  of  retention  form.  We 
rely  upon  the  presence  of  enamel  in  liable  areas  for  resistance 
to  recurrent  caries  and  upon  sound  dentine  for  petention 
form. 


CONVENIENCE  FORM 


CHAPTER    X. 

Convenience   Form. 
Definition.     Convenience  form  is  that  part  of  cavity  prepa- 
ration   wherein   is   made    those   additional   changes   necessary 
for  the  proper  placing  of  a  filling. 

Sparingly  Used.  As  these  additional  cavity  changes  and  its 
accompanving  loss  of  tooth  substance  are  made  entirely  for 
the  convenience  of  the  operator  they  should  be  resorted  to 
only  in   cases  of  necessity. 

Maximum  Convenience  Form.  The  necessity  for  the  use 
of  convenience  form  reaches  the  maximum.  First.  In  inlay 
fillings  as  the  previously  prepared  filling  is  moved  to  position 
en  ni^asse.  Second.  In  the  making  of  a  cohesive  gold  filling, 
as  it  is  of  value  to  apply  force  as  near  as  possible  at  a  right 
angle  to  the  anchorage  of  the  first  portion  of  gold,  and  at 
12  degrees  centigrade  to  all  surrounding  walls.  Third.  In 
cavities  in  the  posterior  teeth,  and  in  distal  cavities  as  com- 
pared with  mesial.  Fourth.  More  is  required  for  proximal 
fillings  not   previously   separated. 

Minimum  convenience  form  is  required  first  in  using  plas- 
tic fillings.  Second,  in  anterior  oral  locations;  third,  where 
the  teeth  have  had  ample  separation  before  the  making  of  a 
proximal    filling. 

The  abuse  of  convenience  form  is  of  harm  to  the  teeth  and 
has  reached  its  height  in  a  desire  to  inlay  every  case  possible. 
When  excessive  cutting  for  convenience  form  is  necessary  to 
the  making  of  an  inlay,  it  would  be  better  many  times  to 
avoid  the  unnecessary  loss  of  tooth  substance  by  changing 
the  character  of  the  filling. 

Suitable  instruments  for  various  locations  in  the  mouth, 
particularly  with  the  posterior  distal  cavities,  will  do  much 
to  minimize  convenience  form. 


68  ESSENTIALS  OF  OPERATIVE  DENTISTRY 

Previous  separation  is  the  most  potent  factor  of  all  in  lessen- 
ing  the  amount  of  cuttings  for  convenience  form,  the  same 
having  been  considered  fully  in  access  form,  and  should  be 
resorted  to  in  cavities  Class  II  and  III  if  for  no  other  reason. 

Starting  points  for  the  making  of  a  cohesive  gold  filling  are 
a  part  of  convenience  form  and  are  made  by  making  one  of 
the  point  angles  more  acute  than  is  required  for  general  re- 
tention. This  is  made  in  the  point  angle  farthest  from  the 
hand  when  the  same  is  in  position  with  the  plugger  point 
resting  on  the  cavity.  This  will  be  found  to  be  the  point 
angle  farthest  from  vision  and  most  difficult  to  fill,  and  from 
the  latter  fact  should  be  the  first  filled.  These  are,  there- 
fore, always  made  in  a  point  angle  at  one  corner  of  the  seat. 


CHAPTER   XI. 


(A)  Removal  of  Remaining  Carious  Dentine. 

(B)  Finishing  Enamel  Walls. 

(C)  Toilet  of  the   Cavity. 

(A)  Definition.  The  secondary  consideration  of  affected 
dentine.  In  the  smaller  cavities  the  previous  steps  in  cavity 
preparation  will  have  removed  all  affected  dentine  and  this 
step  has  little  consequence.  However,  it  is  well  to  have 
this  step  come  to  the  mind  even  in  these  cases  that  the  minute 
corners  and  obscure  localities  are  not  allowed  to  pass  im- 
perfectly prepared. 

In  large  decays  the  pulp  is  many  times  in  question.  The 
dentine  has  been  softened  to  a  near  approach  to  the  pulp.  If 
all  of  this  be  removed  early  in  the  procedure,  the  pulp  will  be 
exposed  to  the  damaging  eft"ects  of  air  drafts  from  the  chip 
blower,  or  possibly  low  temperatures  in  the  operating  room. 
Pulps  thus  exposed  not  infrequently  take  on  the  initial  stages 
of  destructive  diseases  from  which  they  never  recover,  result- 
ing in  much  pain  to  the  patient  and  chagrin  to  the  operator. 
The  foregoing  is  particularly  true  when  making  a  filling  for 
each   of  two   large   proximal   cavities. 


FINISHING  ENAMEL  WALLS  53 

Two  Large  Proximal  Cavities.  It  is  often  desirable  to  pre- 
pare both  cavities  at  the  same  sitting,  particularly  when  filling 
with  amalgam. 

With  the  cavity  first  prepared,  there  might  be  a  long  ex- 
posure of  the  pulp  to  lower  temperatures  if  the  overlying  de- 
cayed dentine  is  removed  at  the  time  the  major  portion  is 
excavated. 

Technic.  The  remaining  decay  in  this  step  of  procedure 
should  be  removed  with  broad  spoon  excavators,  when  work- 
ing on  axial  or  pulpal  walls.  In  small  cavities  where  there 
is  no  danger  of  pulp  exposure  the  instruments  should  be  small 
hatchets,  with  which  the  dento-enamel  junction  should  be 
examined  around  the  entire  cavity.  In  case  a  softened  area 
is  found  and  removed  the  overlying  enamel  should  be  chiseled 
away,  thus  restoring  the  correct  outline. 

Where  exposed  pulp  is  expected  or  pulp  treatment  is  intend- 
ed, the  decay  is  removed  just  following  outline  form. 

(B)  Finishing  Enamel  Walls.  The  last  cutting  done  in 
the  preparation  of  a  cavity  is  the  finishing  of  enamel  walls. 
This  should  always  be  done  with  the  rubber  dam  in  place  or 
at  least  sufficient  means  to  prevent  the  margins  from  again 
becoming  moist. 

No  moisture  should  be  permitted  to  come  in  contact  with 
any  portion  of  the  cavity  surface,  after  final'  instrumentation, 
and  if  by  accident  any  portion  should  become  wet  that  por- 
tion should  be  thoroughly  dried  and  freshened  by  cutting  away 
the  surface,  and  the  filling  immediately  placed. 

The  cavo-surface  angle  of  the  cavity  in  every  part  of  the 
cavity  outline  should  receive  special  attention  at  this  step  in 
cavity  preparation. 

The  plane  of  the  enamel  wall  should  be  so  laid  with  refer- 
ence to  the  cleavage  of  the  enamel  that  these  will  be  cut  more 
from  the  outer  than  the  inner  ends  of  the  rods,  resulting  in  the 
last  rod  at  the  cavo-surface  angle  being  a  full  length  rod,  sup- 
ported by  shortened  rods.  The  shortened  enamel  rods  are 
covered  with  the  filling  material  when  the  completed  filling 
is  in  position. 


60  ESSENTIALS  OF  OPERATIVE  DENTISTRY 

This  is  accomplished  by  a  slight  planing  motion  parallel  to 
the  external  enamel  line,  using  a  keen-edged  chisel  or  enaivel 
hatchet.  The  gingival  margin  trimmers  are  especially  adapted 
for  this  purpose  when  finishing  the  margins  in  the  gingival 
third. 

The  marginal  bevel  should  be  laid  in  a  plane  at  an  angle  of 
from  six  to  ten  centigrades  from  the  plane  of  the  enamel 
cleavage. 

The  depth  of  the  marginal  bevel  should  generally  not  in- 
clude more  than  one-fourth  of  the  enamel  wall,  but  when 
making  a  filling  of  inferior  edge  strength,  as  amalgam,  porce- 
lain, cement,  etc.,  it  becomes  necessary  to  bury  the  bevel  angle 
more   deeply. 

Locations  subject  to  great  stress  also  require  the  placing  of 
the  bevel  angle  more  deeply,  even  carrying  it  beyond  the 
enamel,  laying  the  bevel  angle  in  the  dentine. 

(C)  Definition  of  "Toilet  of  the  Cavity."  The  toilet  of  the 
cavity  is  the  final  step  in  the  preparation  of  the  cavity  and 
consists  of  freeing  the  cavity  of  all  loose  particles  of  tooth 
substance  which  are  not  firmly  attached  to  the  cavity  walls. 

This  is  best  accomplished  by  a  blast  of  air  from  the  chip 
blower,  followed  by  a  thorough  sweeping  and  brushing  of  all 
surfaces  with  cotton  or  spunk  held  in  the  pliers.  Then  again 
using  the  chip  blower  to  remove  dust. 

White  enamel  margins  indicate  the  presence  of  loosened 
enamel  rods.  If  the  sweeping  does  not  remove  this,  the  mar- 
gins should  be  again  chiseled,  using  a  keen-edged  instrument 
and  a  light  hand,  then  again  sweeping  with  cotton. 

If  the  whitened  margin  still  persists,  they  should  be  brushed 
over  with  an  extra  fine  cuttle-fish  disk  or  strip  when  the 
loosened  rods  will  be  carried  away. 

Care  in  the  Use  of  Disk  or  Strip.  It  should  be  fully  under- 
stood that  when  a  disk  or  strip  is  used  for  this  purpose  the 
grit  must  be  so  fine  that  there  is  no  considerable  cutting  done, 
as  there  would  be  danger  of  changing  the  relation  of  bevel 
to  cleavage  of  enamel. 


TOILET  OF  THE  CAVITY  61 

All  Fluids  Should  Be  Used  Previous  to  Cavity  Toilet.     The 

habit  of  swabbing  out  cavities  with  alcohol  or  other  sub- 
stances after  cavity  toilet  is  useless  and  may  do  harm  by 
introducing  substances  with  the  liquid  not  easily  removed. 

Disinfection  and  pulp  protection  should  have  consideration 
following  the  removal  of  remaining  decay  and  as  a  preliminary 
step  in  toilet  of  the  cavity. 

If  a  fixed  oil,  or  an  essential  oil  which  may  contain  impuri- 
ties has  been  used,  free  swabbing  and  scrubbing  of  the  walls 
with  alcohol,  or  sulphuric  ether,  is  advised  for  cleansing  pur- 
poses, to  get  rid  of  the  oil  and  other  residue.  However, 
simply  wiping  the  cavity  out  will  not  suffice.  It  must  be 
thoroughly  rubbed  with  an  alcohol  or  ether-moistened  cotton 
ball,  followed  by  reasonable  desiccation  from  the  chip  blower, 
and  then  every  part  of  the  walls  and  margins  gone  over  and 
freshly  cut.  This  is  the  only  means  of  obtaining  a  clean 
surface. 

Leaks  in  Rubber  Dam,  particularly  near  the  gingival  out- 
line, must. positively  be  detected.  The  portion  which  has  be- 
come wet  should  be  dried  with  an  absorbent  and  the  air  blast. 
Then  all  parts  which  have  been  moistened  nuist  be  gone  over 
and  freshly  cut.  Simply  drying  such  portions  is  not  adequate, 
as  there  is  left  salts  and  albuminoids  from  the  saliva  and  blood 
serum  which  can  only  be  removed  by  the  cutting  instru- 
ments. The  placing  of  a  filling  over  this  gummy  residue  in- 
vites secondary  caries.  These  deposits  will  subsequently  dis- 
solve out,  resulting  in  a  leak.  It  may  be  small  but  the  acid 
of  tooth  decay  will  easily  exchange  places  with  such  films. 

If  the  cleaning  has  been  fairly  well  done,  it  may  result  only 
in   what  is  termed  blue  margin. 

When  time  intervenes  between  cavity  j^reparation  and  the 
making  of  the  filling,  as  from  one  sitting  to  another,  the  walls 
and  margins  should  be  retrimmed  to  give  fresh  cut  surfaces 
to  fdl  against.  This  is  not  possible  in  the  making  of  inlays  a^ 
to  retrim  the  margins  destroys  the  tit.  The  fact  that  many 
times  we  can  not  place  the  inlay  against  surfaces  which  have 


62  ESSENTIALS  OF  OPERATIVE  DENTISTRY 

been  freshly  cut  constitutes  the  greatest  enemy  to  their  perma- 
nence. 

It  is  the  one  great  argument  that  inlays  should  be  made 
at  one  sitting  and  under  dry  conditions. 

Conclusion.  All  fillings  should  be  made  against  clean, 
freshly  cut  walls. 


PART  THREE. 

CHAPTER    XII. 

Examination  of  the  Mouth  Looking  to  Dental  Services. 

The  first  duty  of  a  dentist  to  one  presenting  himself  for 
dental  services  is  to  comply  with  the  patient's  request,  which  is 
generally  to  examine  a  special  tooth  or  a  diseased  condition  of 
which  the  patient  is  aware.  If  the  patient  does  not  make  such 
a  special  request  it  is  well  to  ask  some  form  of  a  leading  ques- 
tion as  to  the  reason  of  the  call.  This  fact  elicited,  all  else 
should  be  ignored  until  the  object  of  the  first  visit  has  been 
accomplished  by  the  patient. 

A  light  hand  and  slow  movements  are  very  essential  for  the 
first  few  moments,  especially  at  the  first  meeting  of  patient 
and  dentist,  as  first  impressions  are  often  lasting  and  if  the 
stranger  is  approached  in  a  careless  manner  he  may  get  ideas 
of  undue  roughness,  many  times  unfounded,  yet,  nevertheless, 
lasting  with  the  nervous  patient. 

The  washing  of  the  hands  in  the  patient's  presence  or  in  run- 
ning water  within  hearing  of  the  patient  should  be  universally 
practiced  no  matter  if  the  operator  knows  his  hands  to  be  al- 
ready scrupulously  clean,  as  it  assures  the  patient  that  the 
operator  has  a  regard  for  at  least  the  simpler  forms  of  cleanli- 
ness. 

The  linen  upon  the  chair  should  be  inviting  and  unsoiled.  If 
convenient,  it  is  well  that  the  patient  see  that  which  is  already 
on  the  chair  changed  for  fresh. 

Few  instruments  should  be  in  sight,  as  they  serve  to  remind 
the  patient  of  former  experiences  not  always  pleasant. 

After  the  first  requests  of  the  patient  have  been  complied 
with  it  is  well  to  take  a  rather  general  survey  of  the  mouth 
before  answering  many  questions  regarding  the  advice  to  the 


64  ESSENTIALS  OP  OPERATIVE  DENTISTRY 

patient  as  to  future  procedures.  The  operator  should  note  in 
this  "bird's-eye-view,"  as  it  were,  the  probable  care  that  is  be- 
ing bestowed  upon  the  teeth  and  mouth  in  a  prophylactic  way. 
Also  the  health  of  the  soft  tissues,  the  number  of  extracted 
teeth,  the  presence  of  dentures  and  amount  of  dental  work 
previously  done,  noting  its  quality  and  probable  age,  as  well 
as  the  number  of  badly  decayed  teeth  yet  unfilled.  He  should 
note  the  health  of  the  patient,  probable  age  and  habits.  All 
this  can  be  done  at  a  glance  and  in  a  few  seconds'  time,  when 
the  operator  will  be  much  better  qualified  to  advise  the  patient 
as  to  what  is  best  to  do  in  a  special  case. 

If  the  patient  is  in  pain  its  alleviation  is  of  first  importance 
and  should  receive  immediate  attention.  It  may  require  the 
application  of  medicinal  remedies,  or  some  mechanical  pro- 
cedure or  even  the  extraction  of  a  tooth,  but,  whatever  it  may 
be,  it  must  be  done  at  once  as  the  patient  is  in  no  mood  to  re- 
ceive sage  advice  about  the  future  when  he  is  at  present  in 
pain. 

Early  in  the  examination  sitting  the  patient  should  be  ad- 
vised of  the  necessity  of  a  prophylactic  treatment  provided  the 
teeth  and  mouth  are  not  scrupulously  clean,  which  is  seldom 
the  case,  unless  the  patient  has  recently  visited  the  dentist  for 
that  purpose. 

This  is  second  only  to  the  relief  of  pain  and  it  is  manifestly 
the  dentist's  duty  to  attend  to  prophylaxis  before  proceeding 
to  the  making  of  fillings. 

A  careful  examination  should  be  suggested,  following  the 
hasty  inspection,  and,  if  advised  to  do  so  by  the  patient,  the 
dentist  may  then  proceed  to  search  all  surfaces  for  the  various 
classes  of  decay,  not  forgetting  the  vulnerable  points  about 
work  previously  placed,  as  the  margins  of  fillings  and  about 
the  bands  of  crowns. 

The  instruments  needed  are,  a  clear,  uninjured  mouth  mir- 
ror, a  sharp  pointed  instrument  called  an  explorer,  cotton  pliers 
and  small  balls  of  absorbent  cotton,  waxed  fioss  silk,  chip 
blower  and  mechanical  separator.  A  small  electric  mouth 
lamp  is  also  of  value. 


EXAMINATION  OF  THE  MOUTH  63 

The  use  of  the  mouth  mirror  is  to  see  therein  the  image  of 
surfaces  and  locations  where  direct  vision  is  imperfect  or  im- 
possible and  to  flood  the  point  being  examined  with  an  abund- 
ance of  light.  ]\Iany  cavities  existing  in  the  proximal  spaces 
are  not  noticed  until  strong  rays  of  light  from  a  different  angle 
than  the  line  of  vision  of  the  examiner  have  been  directed 
against  them. 

The  use  of  the  explorer  is  to  note  the  extent  of  decalcifica- 
tion at  suspected  points  and  the  inspection  of  pits  and  grooves 
for  faults  in  enamel.  This  instrument  should  be  in  the  shape 
of  an  elongated  cork  screw  turn,  that  the  more  inaccessible 
points  may  be  reached.  A  light  hand  in  its  use  is  imperative 
as  the  dentist  is  not  excused  for  breaking  down  tooth  sub- 
stances or  for  causing  much  pain  in  any  of  the  processes  of  ex- 
amination. 

Absorbent  cotton  in  the  pliers  is  used  to  take  up  the  moisture 
in  cavities  of  considerable  size  and  whose  depth  questions 
proximity  to  the  pulp.  Also  sensitive  surfaces  suspected  in 
shallow  cavities,  particularly  those  in  the  gingival  third.  The 
cotton  balls  should  not  be  too  large  and  rather  tightly  rolled. 

Waxed  floss  silk  is  used  to  examine  the  proximal  space 
where  the  reflection  of  light  does  not  make  diagnosis  positive. 
It  cleans  the  surfaces  of  debris  and  food  particles,  giving  a 
deeper  insight  from  the  embrasure.  When  surfaces  are 
roughened  or  cupped  from  incipient  caries,  it  will  show  by  the 
catching  or  cutting  of  the  fibers  of  the  thread,  if  the  surfaces 
still  retain  their  normal  polish  the  thread  will  pass  uninjured. 

The  chip  blower  is  a  small  hand  bellows  for  the  expulsion  of 
air  and  is  used  in  examination  of  the  teeth  to  blow  away  and 
evaporate  the  moisture  from  points  where  it  is  held  by  capil- 
lary attraction,  giving,  thereby,  a  better  view  and  a  more  cor- 
rect idea  as  to  the  color  present,  which  is  a  strong  factor  in  a 
diagnosis  of  conditions  present. 

The  mechanical  separator  will  sometimes  be  of  service  to 
gain  a  little  added  space  for  the  inspection  of  contacting  sur- 
fac'-s. 

The  use  of  the  electric  lamp  on  the  lingual  side  of  the  teeth 


66  ESSENTIALS  OF  OPERATIVE  DENTISTRY 

has  many  advantages  and  is  a  speedy  and  sure  way  of  detect- 
ing any  of  the  stages  of  caries  in  the  proximal  spaces,  the  vi- 
tality of  a  tooth's  pulp  as  well  as  abnormal  conditions  about 
the  alveolar  wall  and  the  presence  of  pus  and  inflammatory 
changes  in  the  maxillary  sinus. 

When  the  examination  is  completed  the  patient  should  be 
advised  of  the  true  condition  of  his  mouth,  including  the  indi- 
cated treatment  of  both  hard  and  soft  tissues.  If  the  patient 
indicates  a  desire  to  have  the  services  rendered  as  outlined  by 
the  dentist  it  is  entirely  good  business,  and  by  no  means  un- 
professional, to  apprise  the  patient  of  the  probable  cost  of  the 
work  as  planned  when  it  can  be  approximately  estimated,  un- 
less the  patient  is  a  frequent  visitor  and  familiar  with  the 
charges  expected  from  the  dentist  consulted. 


ALLEVIATION  OF  DENTAL  PAINS  67 


CHAPTER    XIII. 

The  Alleviation  of  Dental  Pains. 

The  first  duty  of  the  dentist  is  to  relieve  suffering,  and  as  in 
many  instances  this  is  the  reason  for  the  first  call  of  the  pa- 
tient it  is  most  essential  that  the  relief  sought  is  obtained. 
Many  times  the  relieving  of  a  paroxysm  of  pain  by  the  dentist 
has  made  a  lifelong  friend  and  patient. 

The  diagnosis  is  a  most  vital  point  and  the  battle  is  half 
won  when  this  is  correctly  made. 

Pay  strict  attention  to  what  the  patient  has  to  say  as  he  is 
quite  sure  to  give  you  his  symptoms  in  the  order  of  their 
prominence  and  it  is  generally  the  prominent  symptoms  that 
are  pathognomonic. 

After  the  patient  has  given  the  most  aggravated  symptoms, 
make  an  examination  of  the  afflicted  part  of  the  mouth  to  ver- 
ify the  statements  made.  If  all  is  not  clear  quiz  him  more 
specifically.  Do  not  jump  at  conclusions.  The  patient  is  gen- 
erally right  as  to  symptoms  but  frequently  wrong  as  to  loca- 
tion and  cause.  These  last  are  the  points  the  dentist  must  de- 
cide, as  well  as  upon  the  treatment  for  relief. 

There  are  two  divisions  of  dental  pains,  those  arising  from 
lesions  of  the  tooth  pulp,  and  those  arising  from  degenerative 
changes  in  the  sub-dental  tissues,  which  are  generally  the  se- 
quelae of  the  same  destructive  processes  in  the  pulp.  They 
may  follow  the  pulp  troubles  or  occur  simultaneously  with 
them. 

.Sensitiveness  to  thermal  changes.  Tooth  not  necessarily 
sore  to  percussion.  Pain  is  increased  or  induced  when  assum- 
ing a  recumbent  position.  The  presence  of  foreign  substances 
in  the  tooth  cavity,  cause  pain  especially  when  pressed  against 
the  walls  of  the  cavity.  Pain  comes  in  paroxysms  with  a  tend- 
ency to  intermittence.     Patient    may  complain    of  "jumping 


68  ESSENTIALS  OF  OPERATIVE  DENTISTRY 

toothache."  These  symptoms  may  all  be  present  in  the  same 
case  or  only  one  at  a  time  in  the  series  of  changes  that  take 
place  in  a  pulp  from  the  initial  affection  to  its  death. 

The  treatment  for  speedy  relief  is  varied  according  to  the 
most  prominent  symptoms,  as  these  are  the  indications  of  the 
stage  of  dissolution. 

If  cold  air  or  water  causes  pain  of  a  quick,  sharp  shooting 
nature,  comes  on  suddenly  and  passes  off  immediately  upon 
the  tooth  regaining  the  body  temperature,  the  pulp  is  in  the 
stages  of  active  hyperaemia,  which  is  the  initial  stage  of  a  de- 
structive disease,  and  will  respond  immediately  to  the  applica- 
tion of  anodyne  and  effectual  protection  from  air  and  fluids, 
which  is  accomplished  by  stopping  the  cavity  with  a  non-con- 
ductor, generally  cotton,  or  temporary  stopping,  or  an  applica- 
tion of  phenol. 

If  warm  fluids  cause  or  intensify  the  pain  and  the  application 
of  cold  relieves  the  pain  temporarily,  the  pulp  will  be  found  to 
be  well  advanced  in  the  stages  of  dissolution,  some  portion,  of 
which  has  been  resolved  into  the  end  products.  Gaseous  sub- 
stances occupy  portions  of  the  pulp  cavity,  which  is  closed  over 
the  entire  coronal  portion  by  a  layer  of  dentine,  a  filling  or  a 
plug  of  foreign  substance.  These  gases  are  expanded  by  the 
elevation  of  the  temperature,  causing  increased  pressure  upon 
the  remaining  vital  portions  of  the  pulp  and  intense  pain  re- 
sults, which  is  further  augmented,  many  times,  by  the  pulsa- 
tions of  the  heart.  The  pulsating  symptom  in  this  instance  in- 
(.iicates  that  quite  a  portion  of  the  pulp  is  yet  vital. 

The  treatment  for  relief  in  this  case,  which  is  called  closed 
putrescence,  is  the  removal  of  the  obstruction  for  the  escape  of 
the  gas.  This  involves  opening  into  the  pulp  chamber  through 
the  route  of  the  least  obstruction  or  injury  to  the  tooth.  Ne- 
crotic portions  of  the  pulp  should  be  removed,  disinfectants 
and  anodynes  applied  and  devitalization  of  the  remaining  vital 
portion  effected. 

If  moderately  warm  fluids  cause  pain  as  well  as  cold  the  pulp 
is  in  the  first  stages  of  passive  hyperaemia  or  congestion.  This 
condition  is  generally  soon  followed  by  the  symptom  of  being 


ALLEVIATION  OF  DENTAL  PAINS  t)9 

more  painful  upon  the  patient's  lying  down  and  the  throbbing 
pains  setting  in,  and  many  times  patients  will  say,  "I  have  the 
jumping  toothache;"  or,  "It  began  last  evening  about  fifteen 
minutes  after  I  went  to  bed." 

Treatment  of  passive  hyperaemic  pulp  for  relief  is  steriliza- 
tion of  immediate  surrounding  tissue,  as  the  tooth's  cavity  and 
the  application  of  sedatives  and  anodynes.  If  the  pulp  can  be 
bled  with  causing  but  slight  pain  it  is  beneficial ;  then  proceed 
to  devitalization. 

The  painting  of  the  gum  with  a  revulsive  is  of  service,  especi- 
ally if  the  pericementum  is  taking  on  the  stages  of  inflamma- 
tion indicated  by  slight  soreness  to  percussion. 

If  the  presence  of  a  foreign  substance  in  a  cavity  causes  pain 
it  may  be  an  exposed  pulp  which  is  not  very  highly  organized, 
or  hypersensitive  dentine  covered  with  a  layer  of  leathery  de- 
cay. 

The  treatment  is  the  removal  of  the  offending  object  and  the 
prevention  of  its  recurrence  by  temporary  or  permanent  stop- 
ping. 

Pericemental  diseases  causing  pain  have  for  their  most  path- 
ognomonic symptom  the  soreness  to  percussion,  as  shown  by 
gently  tapping  on  the  occlusal  surface  of  the  tooth  with  a  steel 
instrument.  Slight  swelling  of  the  pericementum  causes  the 
tooth  to  appear  to  the  patient  as  much  elongated  and  the  pa- 
tient will  generally  make  such  remarks  as  these,  "I  have  a  sore 
tooth."  "It  hurts  to  close  my  teeth."  "My  tooth  is  too  long," 
etc. 

If  the  pulp  is  entirely  dead,  and  remo\ed,  or  there  is  not  a 
case  of  enclosed  putresence,  thermal  changes  will  have  no 
effect  except  in  rare  cases,  warmth  applied  to  the  parts  will 
give  a  slight  sense  of  relief. 

Treatment  for  the  relief  of  pericemental  pains  is  the  thorough 
and  complete  rcmo\al  of  the  cause,  generally  consisting  of  ne- 
crotic pulp  tissue,  and  infectious  matter  in  the  pnll>  chamber. 
This  should  be  tho'-oughly  removed  by  mechanical  means,  as- 
s'sted  by  the  use  of  chemica's,  and  the  entire  chamber  from 
crown  to  apex  renrlered  aseptic  as  soon  as  possible. 


70  ESSENTIALS  OP  OPERATIVE  DENTISTRY 

If  pus  has  formed  at  the  apical  space  and  flows  freely  down 
the  root  canal  temporary  relief  is  most  certain  to  follow  if  the 
case  is  allowed  to  remain  open  for  twenty-four  or  forty-eight 
hours  for  free  drainage,  when  further  treatment  may  be  pro- 
ceeded with. 

Acute  alveolar  abscesses  should  be  opened  externally,  as 
soon  as  the  presence  of  pus  can  be  diagnosed,  this  to  be  done 
external  to  the  alveolar  wall  and  is  least  painfully  done  by 
freezing  the  tissues  to  be  punctured. 

Abscesses  are  assisted  to  the  surface  by  painting  the  muc- 
cous  membrane  over  the  diseased  portion  with  aconite  and 
iodine.  In  no  case  should  such  an  abscess,  no  matter  what  its 
size,  be  lanced  through  the  external  surface  of  the  face  as  all 
are  easily  reached  from  within  the  mouth. 


PROPHYLACTIC  TREATMENT  71 


CHAPTER  -XIV. 
Prophylactic  Treatment  of  the  Mouth. 

The  importance  of  prophylactic  treatment  early  in  a  series  of 
visits  to  a  dentist  and  at  stated  periods  thereafter,  is  second 
only  to  the  relief  of  pain,  the  neglect  of  which  jeopardizes  the 
remaining  tooth  structures,  the  permanency  of  attempts  to 
check  the  ravages  of  caries  and  disease,  as  well  as  the  reputa- 
tion of  the  operator's  skill. 

Unhygienic  conditions  about  the  Teeth  are  the  sole  immedi- 
ate and  exciting  cause  of  primary  or  secondary  decay  of  the 
teeth,  and  many  an  operator  of  exceptional  skill  as  to  the  mak- 
ing of  fillings  has  failed  from  a  disregard  of  these  conditions. 
As  much  of  the  success  of  dental  operations  depends  upon  the 
care  of  the  mouth  by  both  dentist  and  patient  in  the  way  of 
prophylaxis,  as  upon  the  skill  of  the  dentist  as  an  operator. 
The  making  of  a  filling  is  but  the  repair  of  an  injury  and  is 
only  a  temporary  check  to  the  progress  of  destruction,  if  the 
primary  cause  of  dissolution  is  to  remain  operative. 

The  sub-dental  tissues  are  also  diseased  by  a  lack  of  prophy- 
laxis to  the  extent,  many  times,  of  their  entire  loss,  so  that  the 
teeth,  themselves,  are  loosened  and  lost,  through  a  lack  of 
structures  to  support  them,  while  the  teeth  so  lost  are  many 
times  yet  undecayed,  and,  in  the  present  day  advancement  of 
dentistry,  experienced  operators  are  forced  to  consign  more 
teeth  to  the  forceps  from  the  result  of  diseased  conditions  in 
the  tissues  surrounding  them  than  from  decay  of  the  teeth, 
themselves.  If  this  be  true  the  dentist  cannot  ignore  the  im- 
portance of  combating  the  agencies  which  bring  it  about. 

Preventative  dentistry  has  the  same  great  field  of  usefulness 
as  has  "preventative  medicine"  in  the  practice  of  medicine  and 
the  dentist  who  masters  this  phase  of  the  science  of  dentistry 
has  gone  a  long  way  towards  success,  and  many  defects  in 
manipulation,  abih'ty  and  ideals  in  conditions  about  tooth  re- 


72  ESSENTIALS  OP  OPERATIVE  DENTISTRY 

pair  impossible  of  attainment,  will  stand  the  test  of  time  if 
only  hygienic  conditions  are  attained  and  maintained. 

The  kinds  of  deposits  upon  the  teeth  are  generally  classified 
as  salivary  calculus,  serumal  calculus,  green  stain  and  sordes. 

The  first  two  named  are  enemies  to  tissue  about  the  teeth, 
while  the  last  two  are  responsible  for  most  of  the  destruction 
of  the  hard  dental  tissues  by  caries. 

Salivary  calculus  is  a  calci  precipitated  from  the  saliva.  Lime 
salts  to  the  extent  of  a  little  more  than  2  per  cent  are  held  in 
solution  made  possible  by  the  presence  of  a  little  carbon  diox- 
ide. 

The  reason  for  its  precipitation  is  the  saliva  coming  in  con- 
tact with  oxygen  in  exhaling  and  inhaling,  as  well  as  with  acid 
conditions  in  the  mouth,  causing  a  liberation  of  carbon  dioxide. 
Calcic  portions  of  the  saliva  are  precipitated,  in  a  whitish  pow- 
der, which  collects  upon  stationary  objects  as  the  teeth  or  ar- 
tificial dentures,  subsequently  hardening  into  a  crust  of  a  yel- 
lowish color.- 

The  chemical  anal3^sis  of  solidified  tartar  shows  the  presence 
of  a  small  per  cent  of  food  substances  and  animal  matter. 

The  mouths  most  subject  to  the  deposit  of  salivary  calculus 
are  those  of  individuals  who  from  constitutional  reasons  have 
a  tendency  to  a  superabundance  of  carbon  dioxide  in  the  excre- 
tions and  secretions  which,  of  course,  includes  the  saliva.  This 
is  true  of  those  persons  wherein  the  skin,  kidneys  or,  lungs,  or 
all,  are  not  performing  their  full  functions,  as  these  are  the 
principal  eliminators  of  carbon  dioxide.  Such  individuals  are 
also  liable  to  be  troubled  from  precipitation  within  glands  and 
ducts  before  their  secretions  are  expelled,  resulting  in  cystic, 
glandular,  biliary  and  renal  calculi. 

The  frequency  with  which  the  breath  comes  in  contact  with 
the  saliva  also  has  its  effect,  so  that  the  mouths  of  public 
speakers  and  mouth  breathers,  whether  awake  or  during  sleep, 
are  more  subject  to  its  accumulation. 

The  location  of  salivary  calculus  is  at  the  instant  of  precipi- 
tation on  all  exposed  surfaces  of  the  teeth  and  soft  tissues 
wherever  the  saliva  exists  and  is  most  abundant  where  the 


PROPHYLACTIC  TREATMENT  73 

amount  of  sali^■a  is  the  greatest.  However  the  movement  of 
the  soft  tissues  and  the  friction  against  the  more  exposed  sur- 
faces of  the  teeth,  together  with  the  friction  of  food  upon  the 
teeth,  continually  carries  it  to  the  less  exposed  localities.  The 
surfaces  of  the  teeth,  crownwise  from  the  gum  festoons,  both 
labial  and  lingual  and  particularly  the  embrasures,  become 
favored  retreats  for  salivary  calculus,  where,  if  allowed  to  re- 
main, it  incrustates. 

Serumal  calculus  is  a  calcic  precipitate  from  the  blood.  In- 
organic salts  to  the  extent  of  nearly  1  per  cent  are  held  in  so- 
lution in  the  blood.  The  quality  and  kinds  of  salts  in  solution 
in  the  blood  as  well  as  the  stability  of  suspension  depends  ma- 
terially upon  the  presence  of  a  normal  amount  of  carbon  diox- 
ide. 

Serumal  calculus  is  deposited  beneath  the  gum  tissue  wherein 
there  is  a  passive  h3'peraemic  condition  or  congestion.  Here 
we  have  excessive  tissue  waste,  lessened  alkalimity  of  the 
blood,  a  liberation  of  the  carbon  dioxide  and  consequent  pre- 
cipitation of  the  inorganic  salts.  By  the  recession  of  the  gum 
after  the  formation  of  the  serumal  form  of  calculus,  it  may  be 
exposed  to  view,  or  mixed  with  the  mass  of  salivary  calculus. 

Serumal  calculus  in  appearance  is  of  a  much  darker  color 
than  salivary,  of  a  harder  constituency  and  generally  adheres 
to  the  surface  of  the  tooth  more  tenaciously. 

Serumal  calculus  is  also  found  on  un-exposed  portions  of 
roots  which  approximate  inflammatory  exudates,  or,  are  bathed 
in  escaping  blood  plasma  associated  with  chronic  conditions  of 
the  apical  space.  Also  in  other  portions  of  the  body  as  about 
the  joints  subjected  to  chronic  inflammations  as  well  as  in  the 
glands  continually  gorged  with  blood  and  habitually  congested, 
as  the  liver  and  kidneys,  when  such  deposits  are  known  as 
biliary  and  renal  calculi. 

The  bulk  of  serumal  calculus  is  comparatively  small,  owing 
to  its  formation  in  restricted  spaces  and  is  generally  found  in 
small  nodules,  narrow  bands  and  thin  scales,  not  always  easy 
of  detection  or  removal. 

Stains  upon  the  teeth  are  of  varying  degrees  of  shade  in  sev- 


74  ESSENTIALS  OP  OPERATIVE  DENTISTRY 

eral  colors  and  from  cosmetic  reasons  stand  for  immediate  re- 
moval when  detected.  However  the  green  stain  found  upon 
teeth  is  so  closely  connected  with  the  first  stages  of  caries  on 
surfaces  vSO  affected  that  it  deserves  special  consideration. 

Green  stain  is  generally  confined  to  the  labial  surfaces  and 
particularly  the  gingival  third  of  the  anterior  teeth.  It  is 
most  frequently  found  upon  the  teeth  of  children  and  may  be 
seen  either  upon  the  temporary  or  permanent  teeth.  When  it 
persists  for  a  considerable  time  upon  these  surfaces  of  the  per- 
manent teeth  the  enamel  will  be  found  to  be  etched  by  a  dis- 
solution of  the  cemental  substance  evidenced  by  the  whitened 
surface. 

The  color  is  due  to  the  bacteria  present. 

Tht  injury  to  tooth  substance  is  due  to  the  acid  which  these 
bacteria  produce. 

The  reason  for  their  presence  is,  the  favorable  place  for  lodg- 
ment afforded  by  the  persistence  of  the  cuticula  dentis. 

Sordes  consists  of  a  mixture  of  food,  epithelial  matter  and 
micro-organisms  collected  upon  the  teeth. 

Neglect  in  the  removal  of  which  results  in  tooth  caries,  par- 
ticularly in  localities  habitually  so  unclean. 

The  removal  of  salivary  calculus  is  accomplished  by  two 
principal  plans,  the  push  cut  method  and  the  draw  cut  method, 
each  with  its  advantages. 

By  the  push  cut  method  the  blade  of  the  scaler,  which  has  a 
blunt  chisel  edge,  is  forced  between  the  calculus  and  enamel 
traveling  in  the  direction  of  the  root.  In  its  use  the  principal 
danger  is  the  slipping  of  the  instrument  to  the  gum  tissue  be- 
yond and  this  accident  should  be  well  guarded  against  by  first 
securing  a  positive  and  sufficient  hand  rest. 

By  the  pull  cut  method  the  blade  of  the  scaler,  which  has  a 
hoe  point  of  about  twenty-eight  degrees,  is  first  passed  under 
the  free  margin  of  the  gum,  its  point  engaged  on  the  ledge  of 
the  calculus  and  its  removal  accomplished  by  a  pulling  force 
applied  toAvard  the  crown  of  the  tooth,  or  in  a  plane  parallel 
with   the   long  axis   of  the  tooth.      Care  should  be   taken   in 


PROPHYLACTIC  TREATMENT  71 

passing-  the  instrument  under  the  free  margin  not  to  lacerate 
the  gums.  Pen  grasp  should  be  used  and  a  secure  hand  rest 
obtained  before  making  an  effort  to  remove  the  deposit. 

The  order  of  procedure  is  that  which  requires  the  least 
changing  of  instruments  and  will  therefore  depend  upon  the 
extent  of  the  set  being  used.  In  sets  having  rights  and  lefts 
the  one  best  fitted  to  reach  the  buccal  surfaces  of  the  teeth  of  a 
given  side,  say,  the  lower  teeth,  as  well  as  an  equal  number  of 
surfaces  on  the  upper  teeth.  Thus  one  each  right  and  left  in- 
strument will  reach  eight  localities,  causing  the  change  of  in- 
struments but  once. 

The  first  teeth  to  be  scaled  is  not  important,  yet  if  attention 
is  first  directed  to  the  lingual  surfaces  of  the  lower  incisors,  we 
are  able  to  create  an  impression  upon  our  patients  of  the  im- 
portance of  the  work  in  hand.  It  is  here  we  generally  find  the 
heaviest  deposits  and  by  removing  these  first,  and  allowing 
them  to  fall  in  the  mouth  the  patient  is  fully  awakened  to  the 
need  of  the  service  being  rendered.  The  same  impressions 
never  seem  possible  if  the  removal  of  the  larger  masses  is  left 
until  the  last. 

The  proximal  surfaces  are  best  scaled  with  the  pruning 
hook,  draw-cut  scaler  or  the  straight  push-cut  having  a  very 
thin  blade  and  about  a  twenty-three  degree  bevel. 

These  proximal  surfaces  will  need  such  attention  more  from 
the  deposit  of  serumal  calculus  than  from  the  salivary  variety, 
which  is  only  present  in  the  proximal  surfaces  after  gum  re- 
cession. 

The  removal  of  serumal  calculus  is  much  more  difficult  than 
salivary,  as  all  of  the  work  is  done  under  tlie  cover  of  the  gum, 
which  requires  delicacy  of  touch  and  the  highest  degree  of 
digital  skill. 

Calculus  must  be  distinguished  from  cementum,  bone  and 
soft  tisssues,  simply  by  the  sensation  of  touch  conveyed 
through  contact  of  the  instrument  with  the  structures  in  ques- 
tion. 

The  surface  of  roots,  where  the  attachment  of  the  pcrice- 


76  ESSENTIALS  OP  OPERATIVE  DENTISTRY 

mentum  has  been  lost,  must  be  carefully  examined  and  the  re- 
moval of  all  calculus  accomplished,  as  the  gum  will  not  regain 
health  where  particles  of  the  deposit  remain. 

More  than  one  sitting  is  often  necessary  to  accomplish  satis- 
factory results. 

The  removal  of  green  stain  is  principally  accomplished  by 
the  application  of  some  abradent,  as  pumice  stone,  with  a  re- 
volving brush  in  the  dental  engine.  This  also  polishes  the 
crowns  of  the  teeth,  removing  the  small  particles  of  calculus 
still  adhering  to  them  after  scaling. 

Hydrogen  dioxide  added  to  the  powdered  pumice  in  place  of 
water  will  assist  in  removing  the  stains  and  particularly  green 
stain,  of  which  it  is  a  partial  solvent.  Following  the  use  of 
pumice  and  H^O^.,  the  gums  should  be  thoroughly  syringed 
with  water  to  remove  any  trace  of  the  pumice,  which  is  in- 
soluble in  the  mouth  and  should  not  be  left  around  the  free 
margins  of  the  gums. 

A  clean  new  brush  wheel  should  be  used  and  a  fresh  mix  of 
the  powder  made  for  each  patient  as  a  means  of  preventing  the 
transmission  of  disease  as  well  as  from  the  standpoint  of  clean- 
liness. As  well  might  our  patients  be  asked  to  all  use  the  same 
tooth  brush,  a  thing  not  thought  of,  even  by  members  of  the 
same  family. 

The  removal  of  sordes  is  a  matter  which  must  be  left  to  the 
efforts  of  the  patients.  Its  accumulation  about  favorable  por- 
tions of  the  teeth  and  mouth  is  but  the  matter  of  a  night  or  a 
day  and  upon  its  speedy  and  frequent  removal  depends  the 
salvage  of  the  teeth  from  the  ravages  of  caries. 

The  toothbrush  is  the  one  great  cleansing  agent  and  nine- 
tenths  of  the  removal  of  sordes  is  accomplished  purely  by  me- 
chanical abrasion  through  the  movements  of  the  bristles  of 
the  brush  over  the  surface  of  the  teeth.  The  movements  of  the 
bristles  should  be  not  only  crosswise  to  the  long  axis  of  the 
teeth,  but  also  from  root  to  crown  and  vice  versa,  that  the 
travel  of  the  bristles  may  parallel  the  gingival,  enter  the  em- 
brasures and  traverse  the  grooves  and  fissures. 

Hydrogen  dioxide  is  the  only  agent  which  can  be  used  in  the 


PROPHYLACTIC  TREATMENT  77 

mouth  in  sufficient  strength  to  dissolve  sordes  and  not  injure 
either  the  hard  or  soft  oral  tissues.  This  may  be  used  either 
upon'the  brush  or  as  a  mouth  wash.  The  dissolution  of  sordes 
is  accomplished  by  oxidation. 

The  massage  of  the  gums  is  advised  to  remove  all  unsolidi- 
fied  calculus,  food  particles  and  other  foreign  substances  from 
beneath  the  free  margins  of  the  gums  as  this  appears  to  be  the 
only  satisfactory  method  of  cleansing  these  spaces.  The  mas- 
sage is  also  most  beneficial  to  the  gums.  It  stimulates  the  cir- 
culation, retards  tissue  waste  and  lessens  the  deposit  of  ser- 
umal  calculus,  and  in  addition  forces  away  that  which  has  been 
precipitated  before  it  has  had  an  opportunity  to  solidify. 

Instructions  to  patients  as  to  the  care  of  their  teeth  is  an  all- 
important  duty  of  the  dentist,  not  only  from  the  standpoint  of 
what  is  best  for  the  patient,  but  much  of  the  dentist's  reputa- 
tion as  an  operator  depends  upon  the  subsequent  care  given 
the  teeth  by  the  owner  following  the  making  of  fillings,  for 
upon  their  environment  depends  their  permanency.  Compara- 
tively few  individuals  know  how  to  properly  care  ror  the  mouth 
and  many  will  insist  to  their  dentist  that  they  are  most  careful 
of  their  oral  habits  when  upon  examination,  the  dentist  finds 
surfaces  which  appear  never  to  have  been  cared  for  in  the 
least.  Thev  have  failed  to  reach  these  surfaces  with  their 
brush. 

The  technic  of  proper  brushing  should  be  thoroughly  ex- 
plained, with  special  reference  to  reaching  the  surface  which 
they  seem  to  be  neglecting.  Instruct  them  as  to  the  massage 
of  the  gums  with  the  finger  tips,  rubbing  not  only  cross  wise 
but  also  from  root  to  crown,  assuring  them  that  if  the  gums 
bleed  easily  it  is  all  the  more  essential  that  they  repeat  the  op- 
eration and  that  finally  they  will  regain  their  normal  health 
and  then  they  will  n<it  bleed  under  the  treatment  advised. 

The  use  of  floss  silk  for  i)assing  through  ihe  proximal  spaces 
to  clean  contacting  surfaces  by  wiping  off  the  embrasures  and 
reaching  points  inaccessible  to  the  brush,  should  be  demon- 
strated to  the  patient. 


78  ESSENTIALS  OF  OPERATIVE  DENTISTRY 

Care  should  be  taken  not  to  snap  the  thread  past  contact 
points  as  it  may  lacerate  the  gums. 

Toothpicks  ha\e  no  place  in  the  care  of  teeth  and  should  be 
prohibited  by  law,  especially  those  of  soft  wood  so  commonly 
found  on  the  market  and  at  public  eating  houses.  Their  square 
corners  and  slivered  ends  irritate  the  gums,  causing  their  dis- 
ease and  recession  thereby  destroying  the  natural  protection  to 
the  most  vulnerable  portions  of  the  teeth. 


CHAPTER    XV. 

Exclusion  of  Moisture. 
The  exclusion  of  moisture  from  most  operations  upon  the 
teeth  is  essential ;  to  the  successful  manipulation  of  most  filling 
materials ;  the  sterilization  of  tooth  structures  and  the  preven- 
tion of  infection  ;  the  cleanliness  of  cavity  walls  and  margins  ; 
that  a  perfect  view  of  the  cavity  may  be  obtained ;  that  the  ex- 
tent of  decalcification  may  be  observed ;  to  diminish  the  pain 
of  operations  on  living  dentine  and  to  protect  the  soft  tissues 
from  injury  in  the  use  of  caustic  drugs,  as  well  as  to  save  time 
of  both  patient  and  operator. 

The  methods  of  securing  dryness  during  operations  are  : 
The  rubber  dam  invented  and  given  to  the  dental  profession 
in  1864  by  Dr.  Sanford  C.  Barnum  of  New  York  City. 

Other  Means  of  Dryness. 

The  use  of  absorbents  as  napkins,  cotton  rolls  and  pads 
packed  about  the  teeth  and  near  the  mouths  of  ducts,  assisted 
by  specially  constructed  clamps  upon  the  teeth. 

Also  by  the  use  of  the  saliva  ejector  whereby  the  mouth  is 
continually  drained  of  the  secretions. 

The  objections  to  the  use  of  the  rubber  dam  are  entirely  on 
the  part  of  the  patient  and  can  generally  be  traced  to  awkward 
and  unskilled  handling  on  the  part  of  the  operator.  Every 
operator  should  become  dexterous  with  each  method,  that  he 


EXCLUSION  OF  MOISTURE  79 

may  employ  the  one  most  expedient  in  every  case,  using  the 
one  least  objectionable  to  the  patient. 

The  neglect  of  dr3mess  in  dental  operations  is  to  invite  dis- 
aster in  root  canal  treatment,  as  well  as  short  life  to  all  fillings 
so  placed,  and  the  operator  who  makes  it  a  practice  to  neglect 
this  essential,  obtains  only  a  partial  success  in  that  which  he 
attempts. 

So  important  is  drjmess  that  a  patient  should  be  warned  that 
a  certain  operation,  where  moisture  has  been  allowed  to  flood 
the  field,  is  short-lived  at  best  and  is  liable  to  failure 
from  this  cause.  Such  conditions  seldom  arise  but  are 
occasionally  met  with,  due  to  location  and  extent  of  decay  and 
also  from  the  fact  that  there  are  some  patients  who  are  nause- 
ated by  the  presence  of  the  dam  or  absorbents  about  all  but 
the  most  anterior  teeth. 

All  filling  materials  are  better  manipulated  under  dry  con- 
ditions at  some  stage  of  the  operation,  porcelain  being  the  only 
one  demanding  moist  conditions  at  any  stage  of  the  process. 
This  moisture  in  porcelain  filling  is  only  required  to  preserve 
the  shade  of  the  tooth  substance  to  be  imitated  in  the  fused 
filling. 

Those  to  which  dryness  is  most  essential  are,  cohesive  gold, 
cement  -and  gutta-percha,  named  in  the  order  of  the  import- 
ance of  the  demands.  It  is  true  that  all  of  these  may  be  suc- 
cessfully manipulated  under  moist  conditions,  but  the  effort  is 
greater  and  the  certainty  of  success  is  materially  decreased. 

The  exclusion  of  moisture  for  sterilization  and  the  preven- 
tion of  infection  is  imperative  in  the  last  stages  of  cavity  prep- 
aration, as  it  is  physically  impossible  to  properly  perform  the 
toilet  of  the  cavity  and  properly  sterilize  the  same  when 
flooded  or  even  under  moist  conditions. 

The  proper  treatment  of  pulp  canals  cannot  be  accomplished 
when  flooded  by  the  oral  fluids  to  say  nothing  of  the  introduc- 
tion of  a  permanent  root  filling.  The  saliva  is  at  all  times  im- 
pregnated with  various  forms  of  bacteria.  Its  presence  invites 
failure  by  preventing  sterilization  of  canals  already  septic  and 
permitting  the  re-infection  of  those  already  sterile. 


80  ESSENTIALS  OF  OPERATIVE  DENTISTRY 

Cavity  walls  and  particularly  the  beveled  margins,  must  be 
freshly  cut  and  planed  after  being  moistened  before  the  intro- 
duction of  a  filling,  as  this  is  the  only  means  of  having  an  ab- 
solutely clean  surface.  AVe  may  resort  to  absorbing  and  evap- 
orating the  moisture  from  the  walls  and  margins  of  a  cavity, 
but  there  will  invariably  be  left  a  residue  or  film  upon  the 
surface  which  is  soluble  in  the  oral  fluids.  No  amount  of 
pressure  in  introducing  the  filling,  be  it  rubber,  amalgam  or 
cohesive  gold,  will  displace  the  moisture  absorbed  by  the 
cavity  surfaces,  hence  we  have  this  layer  of  moisture  or  sedi- 
ment intervening  the  filling  and  cavity.  This  will  be  ex- 
changed in  course  of  time  for  that  upon  the  outside  carrying 
with  it  bacteria  and  the  products  of  fermentation  or  lactic  acid 
and  secondary  caries  is  the  result.  A  molecule  of  water  is  so 
small  that  we  have  no  conception  of  its  size  and  no  means  of 
measuring  it.  Bacteria,  which  are  the  active  agents  of  caries, 
will  go  where  moisture  will  not,  and  the  lactic  acid  which  they 
secrete  will  go  where  the  space  is  too  small  for  the  bacteria. 
It  will  therefore  be  readily  seen  that  a  moist  surface  or  one 
coated  with  a  residue  of  an  evaporated  mixture,  whether  medi- 
cine or  saliva,  intervening  between  a  filling  and  a  cavity  wall, 
becomes  a  large  passage  way  for  the  greatest  enemy  to  tooth 
substance — lactic  acid. 

A  better  view  of  cavity  is  obtained  when  dry,  as  its  outlines 
becom.e  more  distinct  and  its  size  and  shape  better  defined.  No 
mechanic  ever  thinks  of  trying  to  accomplish  his  best  work 
with  the  object  submerged  in  moisture.  The  rays  of  light  are 
broken,  objects  are  distorted  and  distances  misjudged.  The 
dentist  who  does  not  effectually  exclude  the  moisture  from  the 
immediate  neighborhood  of  a  cavity  will  catch  only  a  glimpse 
now  and  then  of  portions  of  a  cavity,  this  being  particularly 
true  of  the  gingival  wall,  except  in  cases  of  gum  recession. 

The  extent  of  decalcification  of  both  dentine  and  enamel  is 
diagnosed  only  when  dryness  is  obtained  to  bring  out  the  colors 
and  shades  of  each  incident  to  these  conditions.  It  is  impossible 
to  make  proper  cavity  extension  until  the  cavity  has  been 
made  dry  and  so  maintained  for  some  time,  as  this  is,  many 


EXCLUSION  OF  MOISTURE  «1 

times,  the  only  means  of  detecting  superficial  caries.  Semi- 
decalcified  tooth  substance,  when  moist,  materially  resembles 
the  healthy  structures  and  must  be  dried  to  detect  its  injured 
condition. 

The  pain  of  cavity  excavation  is  materially  decreased  by  the 
extraction  of  the  moisture  from  the  dentine.  The  protoplasm 
within  the  dental  tubules  is  the  means  of  transmitting  the 
sensation  of  pain  to  the  vital  pulp.  Water  is  a  large  constitu- 
ent of  protoplasm  and  the  extraction  of  this  moisture  through 
extreme  and  continued  dryness  removes  the  media  of  sensi- 
tiveness. It  is  therefore  but  human  that  the  cutting  of  dentine 
be  done  with  the  moisture  excluded. 

When  using  caustic  and  concentrated  drugs  the  moisture 
should  be  excluded,  that  the  drug  may  not  be  carried  away  to 
the  injury  of  adjacent  tissues  and  that  the  drugs  may  not  be 
diluted  to  detract  from  their  efficiency  in  accomplishing  that 
for  which  they  were  used..  Drugs  placed  in  the  cavities  of 
teeth  with  moist  margins  even  when  placed  under  fillings  of 
rubber,  cement  or  amalgam  will  follow  the  moisture  of  these 
margins  to  join  that  without  and  great  damage  to  the  sur- 
rounding tissues  often  results  from  no  other  cause  than  a  lack 
of  the  exclusion  of  moisture  during  the  operation. 

As  a  time  saver  the  exclusion  of  moisture  should  not  be 
overlooked.  With  a  dry  cavity  the  continued  uninterrupted 
view  permits  of  more  continuous  work  by  the  dentist.  He 
does  not  have  to  wait  for  the  patient  to  expectorate,  make  a 
few  remarks  and  leisurely  resume  his  position  in  the  chair, 
not  always  in  the  position  desired  for  operating.  The  operator 
will  also  be  saved  much  time  in  drying  the  cavity  after  each 
flooding.  All  this  takes  valuable  time— much  more  than  is  re- 
quired to  adjust  a  dam. 

The  rubber  dam  is  the  most  dependable  means  of  securing  a 
dry  field  for  operating  and  its  proper  and  speedy  a'djustment 
should  be  mastered.  It  is  made  in  three  thicknesses:  heavy, 
light  and  medium,  the  medium  being  the  weight  best  adapted 
for  all  purposes  where  only  one  weight  is  to  be  kept  at  hand. 
The  size  and  shape  is  of  little  importance  so  long  as  it  com- 

(4) 


82  ESSENTIAUS  OF  OPERATIVE  DENTISTRY 

pletely  covers  the  mouth  after  it  has  been  made  to  isolate  the 
teeth  desired,  as  well  as  cover  the  chin  and  extend  to  either 
side  of  the  mouth  sufficient  for  the  proper  engagement  of  the 
holder.  This  will  require  a  piece  from  five  to  six  inches  square, 
for  all  cases  back  of  the  six  anterior  teeth  and  is  most  fre- 
quently the  size  used  on  the  anterior  teeth.  However,  some 
economy  of  rubber  dam  may  be  practiced  by  cutting  these 
squares  in  two  triangular  pieces,  each  of  which  will  do  for  a 
separate  case.  These  are  applied  with  the  diagonal  of  the 
quadrilateral  (Hypotenuse)  uppermost. 

The  holes  to  receive  the  teeth  should  be  of  the  proper  size 
and  smoothly  cut,  otherwise  there  is  an  increased  liability  of 
being  torn  in  adjustment.  This  is  best  done  by  the  use  of  the 
rubber  dam  punch  to  be  had  at  dental  depots.  However,  in 
the  absence  of  this,  a  very  good  result  is  obtained  by  drawing 
the  rubber  tightly  over  a  tapering  round  handle  of  an  instru- 
ment and  touching  the  sharp  edge  of  a  knife  to  the  rubber 
down  the  side  of  the  handle  when  a  perfectly  round  piece  will 
be  cut  out. 

The  distance  between  the  holes  will  vary  according  to  the 
space  between  the  teeth,  the  height  of  the  festoon  of  the  gum, 
the  weight  of  the  dam  and  the  size  of  the  teeth  to  be  engaged. 
Generally  speaking,  the  holes  are  cut  from  two  to  four  milli- 
meters apart  in  medium  dam.  The  lighter  the  dam  the  farther 
apart  should  be  the  holes.  The  holes  are  farther  spaced  with 
extremely  large  gum  festoons,  also  when  there  is  a  consider- 
able gum  recession.  If  the  holes  are  too  close  together  in 
above  condition  the  dam  may  not  cover  the  entire  proximal 
tissues  and  a  leakage  may  occur,  or  the  gum  septa  may  be  un- 
duly compressed  and  permanent  injur}'-  result  from  strangu- 
lation. If  the  holes  are  too  far  apart  the  rubber  will  wrinkle 
and  bag  at  the  proximal  spaces  and  seriously  hinder  operations 
in  these  localities. 

The  location  of  the  holes  in  the  piece  of  rubber  dam  depends 
upon  the  location  of  the  tooth  to  be  operated  upon  and  the 
teeth  to  be  isolated.  A  beginner  will  do  well  to  first  place  the 
dam  over  the  mouth  in  the  position  desired  for  the  outside 
edges,  request  the  patient  to  open  the  mouth  and  with  the 


EXCLUSION  OP  :\IOISTURE  8.?. 

finger  cause  the  dam  to  come  in  contact  with  the  occlusal  sur- 
faces of  the  teeth  it  is  intended  to  include  and  then  punch  the 
holes  as  this  trial  indicates.  By  this  method  the  operator  will 
soon  become  familiar  with  the  location  in  each  case. 

The  number  of  teeth  isolated  depends  upon  the  location  and 
the  operation  to  be  performed.  For  the  short  treatment  cases, 
sometimes  the  placing  of  one  or  two  teeth  under  the  dam  will 
suffice,  but  in  most  cases  where  fillings  are  to  be  made  and 
polished,  from  five  to  eight  teeth  should  be  included  that  a 
good  view  of  the  field  of  operations  may  be  had  and  the  loose 
folds  of  dam  carried  farther  away  to  avoid  them  catching  in 
the  revolving  points  of  the  engine. 

With  anterior  teeth  the  first  bi-cuspid  tooth  of  either  side 
should  be  included,  as  the  cuspid  from  its  conical  shape  is 
many  times  unsafe  for  a  final  ligature. 

With  bi-cuspids  and  molars  as  the  objective  teeth  in  an 
operation,  there  should  also  be  included  the  teeth  anteriorly  to 
the  m.edian  line. 

The  clamp  should  be  placed  on  the  tooth  back  of  the  one  to 
be  operated  upon,  excepting  in  mesial  cavities  in  second  molars 
when  the  clamp  may  be  placed  on  the  second  molar,  thereby 
avoiding  the  clamping  of  the  third  molar  except  when  abso- 
lutely necessary,  as  with  distal  cavities  in  second  molars. 

The  placing  of  the  dam  requires  the  freedom  of  both  hands 
of  the  operator  and  the  aid  of  an  assistant  is  of  value.  The 
necks  of  the  teeth  upon  which  the  rubber  dam  is  to  be  placed 
should  be  cleansed  of  all  calculus  and  sordes  and  flooded  with 
a  jet  of  water  from  the  syringe.  If  the  gums  show  hypersensi- 
tiveness  they  should  be  bathed  in  a  solution  of  cocaine,  re- 
stricting its  use  to  the  gingival  borders.  Waxed  silk  should 
be  passed  through  the  proximal  spaces  to  clean  them  and  prove 
access  for  the  rubber.  If  sharp  margins  of  cavities  cut  the  silk 
these  should  be  dulled  by  passing  a  thin  ribbon  saw  through 
the  proximal  space  or,  with  the  chisel,  carry  the  margin  suf- 
ficiently into  the  embrasure  to  give  access. 

When  teeth  are  closely  contacted  so  that  the  silk  thread  is 
passed  with  difficulty,  the  rubl^cr  can  be  made  to  pass  more 


84  ESSENTIALS  OP  OPERATIVE  DENTISTRY 

readily  by  the  use  of  soap,  which  is  done  by  placing  the  row  of 
holes  on  the  ball  of  the  index  finger,  occlusal  side  up,  and  rub- 
bing the  soaped  fingers  of  the  other  hand  across  the  holes. 

The  occlusal  side  of  the  rubber  dam  is  that  which  is  to  the 
occlusal  when  the  dam  is  in  position  while ; 

The  gingival  side  is  the  opposite  side  and  is  next  to  the 
gingival  margins  when  the  dam  has  been  applied  to  the  teeth. 

The  method  of  applying  the  dam  is  affected  by  the  fact  of 
whether  a  clamp  is  used  or  not  and  kind  of  clamp  when  one  is 
used. 

With  the  anterior  teeth  we  do  not  generally  use  a  clamp  and 
the  rubber  is  placed  by  commencing  at  one  side  and  then 
crowding  the  rubber  through  each  proximal  space  in  the  order 
they  should  go,  until  the  opposite  side  is  reached.  The  rubber 
dam  holder  should  be  applied  to  one  side  before  commenc- 
ing the  adjustment,  and,  as  soon  as  the  teeth  have  been  forced 
through  the  holes  the  other  side  of  the  holder  should  be  at- 
tached. 

With  posterior  teeth  the  holder  should  be  attached  to  the 
short  side  of  the  rubber  to  prevent  curling  into  the  mouth, 
which  would  be  the  same  side  of  the  dam  as  the  teeth  are  sit- 
uated in  the  mouth,  right  or  left.  Adjust  clamp  to  be  used  as 
this  tooth  receives  first  attention,  while  the  remaining  teeth 
are  one  by  one  pushed  through,  until  the  most  anterior  one  is 
reached,  when  the  remaining  side  of  the  rubber  is  secured  with 
the  holder. 

To  prevent  leakage  around  the  teeth  the  edges  of  the  holes 
must  turn  toward  the  roots.  This  is  accomplished  by  first 
pressing  the  dam  well  against  the  gums  while  grasping  the 
rubber  on  either  side  of  the  tooth  and  drawing  it  tight,  then 
release  the  rubber  so  that  it  slackens  and  gently  move  it  oc- 
clusally.  This  will  generally  have  the  effect  of  inverting  the 
edges.  If  inversion  is  not  complete  pass  a  small  blunt  instru- 
ment, as  a  spatula  or  dull  explorer,  around  the  gingival  to  turn 
the  edge  under. 

The  use  of  the  ligature  is  to  assist  in  inverting  the  edges  ot 
the  holes  in  the  rubber  dam  and  to  secure  the  edges  about  the 


EXCLUSION  OF  IMOISTURE  85 

teelli  in  Ihis  position  against  displacement  by  the  movements 
on  the  part  of  the  patient  or  the  operator. 

Caution  in  the  use  of  ligatures  is  most  important  as  much 
permanent  injury  is  done  the  gingival  attachments  by  the 
careless  crowding-  of  these  on  the  dental  ligaments.  This  is 
particularly  the  case  where  the  proximal  gum.  festoons  are  high 
as  m  these  cases,  especially  with  young  people,  the  attachment 
to  the  tooth  is  also  high.  A  tight  ligature  tends  to  incircle  the 
tooth  in  a  straight  line  and  would  thereby  ride  down  the  high 
proximal  attachments,  if  the  ligature  is  crowded  to  the  full 
height  both  labially  and  lingually.  Hence  either  the  labial  or 
the  lingual  should  not  be  crowded  to  the  full  height  of  the 
crown. 

Ligatures  are  made  of  well  waxed  floss  specially  prepared 
for  the  purpose,  cut  into  lengths  of  about  five  or  six  inches 
Some  economy  may  be  practiced  where  three  teeth  are  to  re- 
ceive ligatures  by  starting  with  a  piece  about  twelve  inches 
long.  Tie  the  first  tooth  in  the  center  of  the  strand  and  when 
the  ends  are  cut  off  enough  remains  for  the  other  two,  thus 
getting  three  out  of  the  amount  usually  used  for  two. 

The  cutting  of  the  loose  ends  may  be  practiced  for  all  th.^ 
teeth  except  the  lower  anterior,  cutting  two  or  three  milli- 
meters from  the  knot.  With  the  lower  anterior  teeth,  ends  of 
two  or  three  inches  should  be  left  from,  each  knot  and  the  far- 
ther ends  of  all  tied  together,  and  weighted  to  overcome  the 
efiforts  of  the  patient  to  elevate  the  lower  lip,  which  endangers 
the  security  of  the  dam. 

The  most  popular  knot  for  tying  ligatures  is  the  "surgeon's 
knot,"  either  full  or  half.  This  knot  is  made  by  passing  the 
ends  around  each  other  twice  before  each  tie  is  made,  for  the 
"full  surgeon  knot,"  while  for  the  "half  surgeon  knot"  this  is 
done  with  only  the  first  half  of  the  knot. 

The  "Wedelstaedt  tie"  is  even  more  secure  than  the  above 
and  is  made  by  using  the  first  half  of  a  "surgeon's  knot"  on 
the  lingual  side  of  the  tooth  first  and  then  passing  contacts 
with  the  ends  on  either  side  of  the  tooth,  complete  the  opera- 


86  ESSENTIALS  OP  OPERATIVE  DENTISTRY 

tion  with  a  "half  surgeon's  knot"  on  the  labial,  thus  circHng- 
the  tooth  with  two  strands. 

The  removal  of  ligatures  from  the  tooth  when  the  operation 
has  been  completed  should  be  accomplished  before  the  rubber 
dam  has  been  disturbed,  and  is  best  done  by  the  use  of  a  small 
sharp  pointed  knife  as  a  No.  1  gum  lancet.  The  thread  should 
be  severed  to  one  side  of  the  knot  on  the  labial  or  buccal  side, 
and  by  grasping  the  knot  with  a  pair  of  pliers,  the  thread  is 
pulled  through  from  that  side. 

Where  amalgam  fillings  have  just  been  completed  in  a  prox- 
imal space  the  ligature  about  a  tooth  so  filled  as  well  as  that 
around  the  proximating  tooth  should  be  cut  so  that  the  part 
lying  gingivally  from  the  fresh  amalgam  will  be  loosened  and 
will  pass  out  to  the  lingual  embrasure.  The  ligature  about  a 
tooth  in  which  there  has  just  been  completed  a  filling  in  both 
the  mesial  and  distal  should  be  cut  on  the  lingual  portion. 
This  action  will  result  in  both  ends  being  loose  ends.  Atten- 
tion to  this  point  will  prevent  the  ligature  plowing  a  ditch  in 
the  amalgam  and  destroying  the  filling,  in  many  cases,  at  the 
gingival-cavo-surface. 

A  good  rule  to  remember  is  with  mesial  fillings  cut  to  the 
mesial  of  the  knot ;  with  distal  fillings  cut  to  the  distal  of  the 
knot  and  where  a  tooth  has  both  mesial  and  distal  fillings  cut 
ligature  on  the  lingual. 

The  selection  of  the  clamp  should  be  made  and  then  tried  on 
the  tooth  it  is  intended  to  be  used  upon.  One  should  be  se- 
cured that  has  jaws  which  fit  the  contour  of  the  tooth  at  its 
gingival  border,  that  will  remain  in  position  and  yet  does  not 
hug  the  tooth  so  tightly  as  to  cause  the  patient  pain  or  in  any 
way  injure  the  soft  tissues. 

The  method  of  applying  the  clamp  with  the  dam  is  to 
stretch  the  rubber  over  the  clamp,  then  apply  the  clamp  forceps 
and  carry  all  to  position  on  the  desired  tooth,  using  the  hole  in 
the  dam  thus  intended  as  a  means  of  getting  a  view  of  the 
tooth  to  be  clamped,  which  aids  in  the  placing. 

Some  of  the  older  makes  of  clamps  require  that  they  first  be 
placed  in  position  on  the  tooth  and  then  with  the  first  fingers 


EXCLUSION  OF  MOISTURE  87 

of  each  hand  sufficiently  distend  the  hole  in  the  rubber  dam  to 
slip  it  over  the  bow  of  the  clamp. 

In  using  cervical  clamps  for  cavities  on  the  buccal  and  labial 
surfaces  in  the  gingival  third  the  dam  is  first  passed  to  position 
and  then  the  clamp  applied. 

The  removal  of  the  rubber  dam  is  accomplished  by  the  fol- 
lov/ing  order  of  procedure : 

First — The  removal  of  the  ligations  as  before  described. 

Second — Pull  the  rubber  to  the  buccal  or  labial  and  with  a 
sharp  pair  of  scissors  cut  strips  passing  between  the  teeth. 

Third — Disengage  one  side  of  the  dam  holder. 

Fourth — With  the  right  hand  remove  the  clamp  which 
should  be  holding  the  rubber  dam,  remove  all  clear  of  the 
mouth  immediately,  as  the  patient  does  not  take  kindly  to  any 
delays  at  this  stage  of  the  procedure. 

Fifth — Inspect  the  rubber  to  see  if  it  has  all  been  removed. 

Sixth — Inspect  the  teeth  for  any  portions  of  rubber  dam, 
ligatures  or  stray  particles  of  filling  material.  Now  proceed 
to  knead  the  gums  with  the  fingers,  at  the  same  time  flooding 
them  with  a  forceful  stream  of  water  from  the  syringe,  to 
cleanse  them  and  to  re-establish  circulation. 

The  use  of  absorbents  may  be  resorted  to  in  place  of  the 
rubber  dam  for  short  operations  and  more  particularly  with 
the  upper  teeth  as  these  are  the  most  easily  managed.  Ab- 
sorbents are  to  be  had  in  the  market  in  the  form  of  rolls  and 
napkins  at  small  cost  and  are  to  be  discarded  after  once  used, 
which  is  the  only  hygienic  method.  In  their  use  particular  at- 
tention must  be  paid  to  the  mouths  of  the  ducts  responsible 
for  the  most  abundant  secretions  and  the  absorbents  so  placed 
as  to  not  only  readily  absorb  the  fluid  which  is  ejected,  but 
also  that  they  compress  the  ducts  thereby  restricting  the  out- 
put. 


ESSENTIALS  OP  OPERATIVE  DENTISTRY 


CHAPTER- XVI. 

The  Treatment  of  Hypersensitive  Dentine. 

Hypersensitive  dentine  is  dentine  which  is  more  than  nor- 
mally responsive  to  mechanical  or  chemical  irritation. 

Normal  healthy  dentine  is  only  slightly  sensitive,  but  when 
exposed  to  abnormal  conditions  and  irritating  agents  it  may 
become  excruciatingly  hypersensitive. 

The  sensations  are  conveyed  to  the  pulp  by  means  of  the 
contents  of  the  dental  tubules  which  are  prolongations  of  the 
odontoblasts.  The  odontoblasts  are  thickly  surrounded  by 
the  terminal  fibers  of  the  nerves  within  the  pulp. 

The  contents  of  the  tubuli  is  largely  protoplasm  and 
although  this  has  the  power  of  transmitting  sensation  in  re- 
sponse to  irritation,  it  has  not  yet  been  demonstrated  that  the 
nerve  fibers  enter  the  tubuli  or  penetrate  their  contents.  Hence 
it  cannot  be  said  that  there  is  nerve  tissue  within  the  dentine. 

The  direct  cause  of  sensitive  dentine  is  the  loss  of  the  enamel 
which  is  the  natural  covering  of  the  dentine. 

The  most  common  agent  in  the  removal  of  this  normal  cov- 
ering is  caries,  which  exposes  the  dentine  to  mechanical  injury 
through  contact  with  foreign  substances  and  chemical  irri- 
tants, particularly  the  acids  of  fermentation. 

Rapidity  of  caries  has  much  to  do  with  the  degree  of  hyper- 
sensitiveness  in  dentine,  as  shown  in  the  white  and  light 
stages  or  rapid  forms  of  caries  wherein  the  sensitiveness  is 
most  exalted,  while  with  the  dark,  yellow  and  brown  varieties 
it  is  not  so  marked  and  with  the  black  or  slow  progressing 
form  of  caries  the  sensitiveness  is  scarcely  above  normal. 

The  most  sensitive  part  of  a  carious  tooth  is  at  the  junction 
of  the  dentine  with  the  enamel  or  cementum  at  the  periphery 
of  the  tubuli.     It  is  therefore  evident  that  the  second  stage  of 


treat:\iext  of  hypersensitive  dentine  89 

caries  will  show  a  higher  degree  of  hypersensitive  dentine  than 
the  deep  seated  stages  and  that  the  preliminary  steps  in  cavity 
preparation  in  this  division  of  cafies  will  be  more  painful  than 
the  deeper  cuts  into  the  dentine,  as  then  the  more  sensitive  part 
has  been  passed. 

Mechanical  abrasion  is  also  an  agent  which  produces  hyper- 
sensitive dentine  by  first  wearing  away  the  enamel  and  then 
encroaching  on  the  dentine.  However,  this  process  may  be  so 
slow  and  the  irritation  so  slight  as  to  act  as  a  stimulus  to  the 
odontoblasts  and  result  in  the  obliteration  of  the  dental  tubuli 
by  the  deposit  of  calcific  matter  termed  "tubular  calcification." 
When  this  is  the  result  all  sensation  may  be  absent. 

Exposure  of  cementum  through  gum  recession  is  another  ex- 
citing cause  of  hypersensitive  dentine  aggravated  by  allowing 
the  accumulation  of  sordes  about  the  exposed  cementum. 

Abnormal  oral  secretions  often  produce  hypersensitive  den- 
tine and  may  be  particularly  looked  for  in  the  convalescent 
stages  of  fevers,  as  -well  as  in  dyspepsia,  neuralgia,  pregnancy, 
pulmonary  tuberculosis  and  acute  rheumatism. 

Hypersensitive  dentine  is  found  in  poorly  calcified  dentine 
including:  The  teeth  of  the  growing  child;  teeth  that  have  not 
been  erupted  for  more  than  a  few  months ;  the  teeth  of  those 
who  follow  indoor  lives,  particularly  if  they  are  under  a  heavy 
mental  strain,  as  well  as  anything  which  may  produce  nervous 
irritation  or  debility. 

The  varying  temperaments  of  patients  must  be  studied  and 
understood  to  best  cope  with  the  problem  of  hypersensitive 
dentine.  The  suffering  is  actual  upon  the  part  of  some,  while 
there  are  those  who  magnify  every  pain  and  seem  to  be  able 
to  stand  nothing  and  make  as  much  fuss  about  a  pin  stick  as 
it  would  be  possible  for  them  to  make  were  they  thrust 
through  with  a  bayonet.  The  operator  must  separate  these 
classes  and  vary  the  methods.  He  must  understand  the  actual 
conditions  and,  by  kind  words  of  encouragement  and  a  positive 
procedure,  stimulate  the  nervous  to  withstand  the  necessary 
pain.  This  can  only  be  done  when  the  operator  has  full  con- 
trol of  his  own  feelings,  seeing  to  it  that  his  temper  is  not 


90  ESSENTIALS  OF  OPERATIVE  DENTISTRY 

ruffled,  for,  having  lost  control  of  himself,  he  has  no  control 
over  the  patient. 

Highly-wrought,  nervous  temperament  is,  by  nature,  sensi- 
tive to  impressions,  especially  augmented  by  environment  or 
occupation  and  calls  for  the  most  skillful  management  of  both 
patient  and  teeth.  They  are  generally  people  of  a  high  order 
of  intelligence  and  when  handled  by  a  master  hand  prove  a 
most  desirable  clientage. 

Patients  of  this  temperament  will  hear  to  being  hurt  for  a 
short  time  provided  something  definite  has  been  accomplished. 
They  should  be  advised  at  times  as  to  the  coming  pain,  and  for 
what  purpose  it  must  be  inflicted,  as  the  forming  of  an  angle 
or  the  flattening  of  a  wall,  explaining,  when  done,  that  that 
which  had  been  intended  has  been  accomplished.  They  will 
stand  for  no  awkwardness  or  fumbling  but  admire  exactness 
and  precision  and  are  the  class  which  will  reward  the  dentist 
most  liberally  for  painstaking  efforts  and  actual  achievements. 
This  class  make  the  day  long  but  they  serve  to  stimulate  the 
dentist  to  his  best  efforts  and  work  to  the  advancement  of  the 
really  progressive  operator. 

The  irresponsible  individuals  who  have  no  mental  or  phy- 
sical stamina  require  a  strong  hand  to  control  them  in  any 
emergency  in  life.  They  go  to  the  dentist  only  when  forced 
there  by  pain  or  are  children  brought  by  their  parents.  While 
a  dentist  should  never  be  harsh  with  any  patient,  yet  this  class 
will  necessitate,  many  times,  stern  commands  and  a  "why,  of 
course"  method.  In  cases  of  this  character  where  the  operator 
has  chosen  to  assume  the  role  of  a  disciplinarian,  the  stern 
proceeding  should  universally  be  tempered  with  the  kindest  of 
tones  before  the  patient  leaves  the  chair  that  the  patient  may 
depart  with  the  impression  that  the  dentist  is  kind  of  heart 
and  has  been  severe  only  for  the  patient's  good. 

The  naturally  cowardly  patient  who  is  strong,  healthy  and 
robust  yet  lives  in  mortal  dread  of  any  physical  discomfort,  is 
the  hardest  class  to  manage.  This  class  of  patients  have  gen- 
erally been  raised  in  luxury  and  taught  by  example  made  pos- 
sible by  their  environment,  that  they  should  not  even  be  incon- 


TREATMENT  OF  HYPERSENSITIVE  DENTINE  91 

venienced.  They  seldom  work  and  mistake  that  tired  feehng 
for  sickness.  To  be  hungry,  cold  or  warm,  is  described  by 
them  as  "simply  terrible."  With  such,  many  times  the  best  an 
operator  can  do  is  simply  to  temporize  to  keep  the  teeth  com- 
fortable. To  attempt  thorough  work  merely  drives  them  away 
to  seek  gas  for  painless  extraction. 

The  patient  who  simulates  pain  should  be  early  detected  and 
severely  dealt  with.  An  operator  should  remember  that  a  large 
amount  of  the  gesticulation,  grabbing  the  working  hand,  cring- 
ing and  outcry,  is  simply  voluntary  on  the  part  of  many  pa- 
tients to  inform  the  dentist  that  he  is  hurting  them.  Most  of 
this  can  be  done  away  with  by  the  following  procedure : 

First  tell  the  patient  that  "this  will  not  hurt  you ;"  then  pro- 
ceed to  make  the  statement  true  by  working  on  enamel  mar- 
gins, even  to  gently  scratching  on  the  external  surface.  Then 
state  to  them  that  "this  may  hurt  a  little"  and  the  operator  can 
proceed  to  test  the  dentine  for  its  sensitive  portions.  He  may 
then  proceed  to  do  the  less  painful  parts  of  cavity  preparation. 
Lastly  when  it  comes  to  cutting  the  angles  and  cutting  sensi- 
tive portions  the  patient  should  be  warned  that  this  particular 
place  may  be  sensitive  but  that  a  certain  amount  of  cutting  is 
necessary.  Advise  the  patient  to  hold  still  for  just  a  second  or 
two  and  then  he  will  be  allowed  to  rest.  Caution  them  against 
moving  during  this  brief  period  as  it  will  undo  what  has  been 
accomplished,  necessitating  their  withstanding  the  pain  again. 
Praise  them  for  their  bravery  when  they  have  complied  with 
the  request  and  advise  them  as  to  the  work  accomplished.  All 
this  instils  confidence  into  the  patient  as  to  the  dentist  know- 
ing what  he  is  about  and  as  to  his  knowledge  of  the  place  and 
time  that  pain  may  be  expected.  Nothing  un-nerves  a  patient 
so  much  as  to  get  the  slightest  idea  that  the  dentist  is  not 
aware  of  the  pain  he  is  inflicting  or  that  he  has  little  care  for 
their  sufferings  and  to  have  no  definite  idea  as  to  when  it  will 
end. 

The  true  simulator  of  pain  will  try  to  make  the  operator 
believe  he  is  causing  pain  when  he  is  not  suffering  at  all,  with 
the  idea  that  the  dentist  will  be  frightened  into  extreme  care 


92  ESSENTIALS  OF  OPERATIVE  DENTISTRY 

in  their  case.  This  class  is  easily  detected  by  scraping  an  in- 
strument on  a  surface  where  pain  is  impossible,  as  the  external 
surface  of  a  tooth.  If  the  demonstrations  continue  it  is  the 
operator's  duty  to  inform  the  patient  of  the  detection  of  the 
attempted  deception  and  that  such  will  not  be  further  consid- 
ered, at  the  same  time  advising  them  to  save  their  demonstra- 
tions until  they  are  hurt  when  they  will  be  considered,  and 
every  effort  made  to  lessen  the  pain. 

The  agents  for  relief  of  sensitive  dentine  are: 

First —  Those  which  produce  a  physical  change  in  the  con- 
tents of  the  tubuli,  as  desiccation,  heat  and  cold. 

Second^Those  agents  which  destroy  or  disorganize  the  con- 
tents of  the  tubuli,  as  caustics  and  escharotics. 

Third — Those  agents  which,  when  applied  to  the  dentine  lo- 
cally, produce  a  condition  of  analgesia  or  absence  of  sensibility 
to  pain  termed  local  anaesthetics  as,  phenol,  menthol,  morphic 
acetas,  oil  of  cloves  and  cocaine. 

Fourth — Those  agents  administered  with  the  view  of  reach- 
ing the  nerves  of  the  pulp  through  the  general  system  as,  bro- 
mide of  potassium,  nitrus-oxide,  chloroform,  etc. 

Fifth — The  mechanical  condition  under  which  the  cutting  of 
sensitive  dentine  is  done. 

First — Physical  Agents. 

Desiccation  is  a  physical  agent  of  great  virtue  in  alleviating 

hypersensitive  dentine  and  accomplishes  the  result  by  extract- 
ing the  moisture  from  the  tubuli,  which  is  a  large  constituent 
of  the  protoplasm. 

This  is  best  accomplished  by  first  flooding  the  cavity  with 
absolute  alcohol  which  has  an  affinity  for  H20.  and  then  di- 
recting into  the  cavity  a  continuous  stream  of  warm  air  which 
is  more  effective  if  the  temperature  can  be  controlled  so  as  to 
gradually  raise  it  to  the  highest  point  tolerable  to  the  patient. 
Painless  cavity  excavation  can  be  accomplished  to  the  depth 
of  desiccation  which  will  vary  with  different  cases. 

A  continuous  stream  of  cold  air  will  have  a  similar  action 
through  its  desiccating  effect  and  is    practiced    where    com- 


TREATMENT  OF  HYPERSENSITIVE  DENTINE  03 

pressed  air  is  at  hand.  The  force  with  which  the  air  is  con- 
tacted with  the  cavity  walls  is  a  factor  in  its  efficiency. 

Heat  and  cold  when  moist  will  produce  physical  changes  in 
the  protoplasm  of  the  tubuli  sufificient  to  destroy  the  sensation 
of  pain. 

In  any  locality  of  the  body  a  moderate  rise  in  the  tempera- 
ture, particularly  moist  heat,  quickens  vital  action  and  height- 
ens functional  activity.  This  is  true  of  sensitive  dentine  and 
the  temperature  must  be  materially  raised  before  a  stage  of 
paralysis  is  reached. 

The  best  means  of  applying  this  method  is  to  direct  into  the 
protected  cavity  a  forceful  fine  stream  of  water  which  can  be 
gradually  raised  in  temperature  to  the  point  of  toleration,  cut- 
ting the  sensitive  part  of  the  cavity  while  the  stream  of  water 
is  still  playing  on  the  point  being  operated  upon. 

With  the  application  of  cold  to  any  part,  vital  phenomena 
of  every  nature  is  retarded  and  entirely  ceases  with  the  lower 
temperatures. 

The  best  method  of  applying  this  principal  is  to  spray  the 
cavity  with  a  highly  volatile  liquid  as  ethyl  chloride,  sulphuric 
ether  and  its  combinations  with  chloroform.  The  rapid  evap- 
oration lowers  the  temperatures,  extracting  the  heat  from  that 
with  which  it  comes  in  contact. 

The  primary  pain  in  applying  these  agents  may  be  lessened 
by  filling  the  cavity,  temporarily,  with  stopping,  directing  the 
spray  first  on  this  and  the  surrounding  parts  and  later  remov- 
ing the  stopping,  directing  the  spray  into  the  cavity  without 
causing  much  pain,  provided  there  is  not  a  hyperaemic  pulp 
within  the  tooth,  when  all  thermal  changes  must  be  avoided. 

The  electric  current  (cataphoresis)  as  a  physical  agent  to 
obtund  sensitive  dentine  should  be  mentioned.  It  has  been 
used  to  assist  in  carrying  various  drugs  into  the  dentine,  to 
facilitate  their  activity,  but  its  use  has  proved  so  unsatis- 
factory, in  many  ways,  that  further  description  of  this  method 
is  unwarranted. 

Second — Destroying  Agents. 


94  ESSENTIALS  OF  OPERATIVE  DENTISTRY 

Caution  in  the  use  of  caustics  and  escharotics  to  relieve  sen- 
sitive dentine  in  deep  seated  cavities  will  save  much  pulp  com- 
plications and  great  care  must  be  exercised  in  their  use  not 
only  for  the  safety  of  the  pulp  but  also  the  soft  tissues  about 
the  tooth  must  be  effectually  protected.  Many  caustics  are  not 
limited  in  their  action  and  when  once  applied  on  the  dentine 
continue  their  destruction  to  the  envelopment  of  the  pulp. 
Arsenic  trioxide  is  a  notable  example  of  this. 

Lime  chloride  is  one  of  the  oldest  and  most  efficient  remedies 
for  hypersensitive  dentine.  Its  action  is  due  to  its  affinity  for 
water  and  its  coagulating  properties  upon  albumen. 

The  danger  in  its  use  in  deap  seated  cavities  is  through  the 
liberation  of  hyrochloric  acid,  which  causes  pain  in  case  of  a 
nearly  exposed  plup.  This  effect  may  be  modified  by  using  it 
in  a  solution  of  one  part  chloroform  and  four  parts  alcohol.  Add 
the  zinc  crystals  to  the  proportion  of  five  grains  to  the  ounce. 
Clarify  by  adding  a  drop  of  hyrochloric  acid. 

The  methods  of  using  zinc  chloride  are : 

First — Saturate  a  pellet  of  cotton  with  the  above  solution, 
place  in  the  cavity  and  evaporate  with  a  draft  of  warm  air  from 
the  warm  air  syringe  or  chip  blower. 

Second — Mix  a  thin  paste  of  zinc  oxychloride  cement.  Paint 
the  sensitive  dentine  with  this  cement  and  cover  with  stopping" 
or  gutta-percha.  After  a  few  days  or  weeks,  many  times,  ex- 
cavation may  be  accomplished  with  little  pain. 

Caustic  potassa  and  carbolic  acid,  equal  parts,  (Robinson's 
remedy),  often  relieves  sensitiveness  of  the  dentine  and  is  ap- 
plied by  placing  a  pledget  of  cotton  in  the  cavity,  always  with 
the  rubber  dam  in  position  to  protect  soft  tissues. 

Silver  nitrate  may  be  employed  to  good  effect  upon  exposed 
surfaces  of  dentine  in  the  posterior  parts  of  the  mouth,  such  as 
those  on  the  occlusal  of  molars  due  to  abrasions,  or  exposed 
cementum.  It  reduces  sensitiveness  and  by  forming  the  albu- 
minate of  silver  it  retards  decay  even  so  far,  in  some  cases,  as 
to  render  the  surfaces  to  which  it  has  been  applied,  immune  to 
caries.  On  account  of  its  discoloring  effect  its  use  is  not 
permissible  in  parts  exposed  to  view. 


TREATMENT  OF  HYPERSENSITIVE  DENTINE  95 

Third — Local  Anaesthetics  and  Anodynes. 

Cocaine  stands  first  as  a  local  anaesthetic  to  desensitize  den- 
tine. It  is  possessed  of  two  virtues,  both  of  which  render  it  of 
value  as  a  desensitizer  of  dentine. 

First — It  is  a  protoplasmic  poison  and  when  forced  into  the 
dentine  or  absorbed  by  the  contents  of  the  tubuli  it  poisons  the 
protoplasm  and  destroys  the  power  of  transmitting  sensation. 

Second — It  paralyzes  the  terminal  fibers  of  the  sensory 
nerves  and  when  it  reaches  the  odontoblastic  layer  of  the  pulp 
its  action  is  most  prompt  and  profound.  However  this  latter 
effect  is  never  sought  unless  pulp  extirpation  is  intended  which 
will  be  fully  considered  in  the  chapter  on  pulp  devitalization. 

The  methods  of  using  cocaine  for  sensiti\'e  dentine  are  slow 
absorption  and  injection  by  pressure. 

The  slow  absorption  method  is  best  practiced  by  putting  into 
the  cavity  a  one-sixth  grain  tablet  of  pure  cocaine ;  over  this 
place  a  pledget  of  cotton  which  has  been  moistened  with  the 
normal  salt  solution,  and  proceed  to  fill  tooth  with  stopping, 
seeing  the  cavity  again  for  excavation  in  twenty-four  or  forty- 
eight  hours. 

Pressure  anaesthesia  of  the  dentine  may  be  accomplished  in 
two  general  ways.  The  dentine  should  be  thoroughly  steril- 
ized, the  above  application  of  cocaine  in  the  normal  salt  solu- 
tion made  and  over  this  place  a  piece  of  unvulcanized  rubber 
and  all  crowded  into  the  cavity  with  as  much  force  as  the  pa- 
tient will  permit. 

High  pressure  syringes  are  sometimes  of  service  to  simply 
desensitize  the  dentine,  but  their  use  for  this  alone  has  never 
become  general  practice,  due  to  the  danger  of  pulp  infection, 
and  affection. 

Phenol  (known  to  the  laity  as  carbolic  acid),  is  a  valuable 
remedy  for  hypersensitive  dentine,  as  well  as  for  materially 
lessening  the  pain  caused  by  the  blast  of  air  from  the  chip 
blower,  and  should  never  be  forgotten  when  the  patient  com- 
plains of  the  air  causing  pain.  In  addition  to  coagulating  the 
albumen  in  the  tubli  it  possess  analgesic  properties. 

The  method  of  using  phenol  for  sensitive  dentine  is  to  care- 


96  ESSENTIALS  OF  OPERATIVE  DENTISTRY 

fully  desiccate  the  dentine  with  alcohol  and  warm  air,  apply  a 
pledget  of  cotton  saturated  with  the  phenol,  directing  thereon 
a  current  of  warm  air  until  the  cotton  is  nearly  or  quite  dry. 
This  should  be  repeated  as  often  as  the  case  demands. 

Oil  of  cloves  is  a  valuable  remedy  in  this  respect  and  the 
method  of  its  use  is  the  same  as  that  just  described  for  phenol. 

Oil  of  cloves  and  phenol  combined,  as  two  parts  phenol  and 
one  part  oil  of  cloves,  applied  to  the  dry  open  cavity  and  evap- 
orated therefrom,  with  the  current  of  warm  air,  is  more  effect- 
ive than  either  the  phenol  or  oil  of  cloves  alone.  This  method 
with  these  agents  has  to  recommend  it  the  fact  of  being  a  good 
means  of  sterilization,  it  is  a  pulp  pacifier  in  deep  cavities,  and 
no  injury  can  reach  the  pulp,  provided  the  temperature  of  the 
current  of  warm  air  is  not  too  high. 

Fourth — Through  the  General  System. 

Potassium  bromide  in  drop  doses  three  times  a  day  for  forty- 
eight  hours  previous  to  a  sitting  at  the  dentist's  will  do  much 
to  remove  the  nervousness  caused  by  the  fear  of  the  intended 
visit  and  serve  to  minimize  the  pain  to  be  endured. 

Nitrus  oxide  is  of  service  in  extreme  cases  where  the  opera- 
tion is  short,  as  the  sharpening  of  angles,  or  the  making  of  a 
convenience  angle  for  starting  a  filling.  But  the  operator  must 
have  the  full  co-operation  of  the  patient  with  all  absence  of 
fright. 

Chloroform  slowly  administered  and  only  to  the  first  stage 
of  anaesthesia  is  a  most  valuable  means  of  dealing  with  severe 
cases.  This  is  particularly  true  of  the  A.  C.  E.  mixture  (alco- 
hol, chloroform  and  ether,  equal  parts).  The  primary  effect 
is  to  paralyze  the  sensory  nerves,  as  the  ends  of  the  fingers,  the 
skin  and  mucous  membrane  in  general  and  this  is  true  in  the 
tooth's  pulp  with  the  fibers  ending  in  the  odontoblastic  layer 
of  cells  wherein  abundant  sensitiveness  has  been  developed. 

The  method  of  administration  is  quite  the  same  as  that  for 
any  other  operation  except  that  it  is  not  carried  past  the  first 
stage  of  anaesthesia.  All  that  part  of  the  preparation  of  the 
cavity  not  producing  pain  is  carried  out,  after  which  the  dental 
chair  is  tipped  back  to  as  recumbent  a  position  as  will  admit  of 


TREATMENT  OF  HYPERSENSITIVE  DENTINE  97 

Operating.  A  napkin  is  then  spread  over  the  lower  part  of  the 
face  .leaving  the  eyes  uncovered.  The  chloroform,  or  better 
the  A.  C.  E.  mixture,  is  added,  first  slowly  a  drop  or  two  at  a 
time  and  carried  to  the  point  where  the  patient  feels  a  tingling 
sensation  in  the  finger  tips  or  expresses  the  fact  that  they  be- 
gin to  feel  the  effects  of  the  drug.  The  anaesthetic  should 
never  be  crowded  or  confined  while  the  patient  can  smell  the 
chloroform,  but  can  be  pushed  more  rapidly  when  the  olfactory 
nerves  have  been  paralyzed,  so  that  the  sense  of  smell  is  lost, 
and  it  is  not  long  thereafter  until  the  dentine  can  be  excavated 
painlessly.  As  soon  as  the  operator  begins  to  operate  the  as- 
sistant should  hold  to  the  nostrils  a  large  mouthed  bottle  of 
the  anaesthetic  to  prolong  the  stage  of  anaesthesia  reached.  At 
no  time  should  the  patient  be  sufficiently  under  the  influence  of 
the  anaesthetic  to  be  unable  to  converse  coherently  or  intelli- 
gently answer  the  questions  put  to  them. 

It  must  be  remembered  that  any  anaesthetic  has  its  dangers, 
particularly  when  its  use  is  abused,  but  the  above  method  can 
be  recommended  as  comparatively  safe.  One  writer  reports 
its  use  in  over  20,000  cases  without  ill  efifects.  It  is  true  that 
a  large  per  cent  of  the  cases  wherein  death  has  resulted  from 
the  administration  of  chloroform  or  ether  have  occurred  in  the 
first  few  breaths,  as  we  believe  due  to  a  strong  mixture  used  at 
first  or  before  the  nerve  filaments  of  the  air  passages  have  been 
anaesthetized. 

If  a  few  breaths  administered  as  above,  by  the  open  method, 
proved  fatal,  literature  would  be  replete  with  long  accounts  of 
druggists,  physicians,  dentists  and  others  having  met  death  by 
smelling  of  opened  bottles  of  these  drugs. 

Rapid  Breathing  as  a  means  of  producing  peripheral  anaes- 
thesia should  receive  consideration,  not  only  for  hypersensi- 
tiveness  of  the  dentine  but  for  other  minor  dental  operations 
as  the  use  of  hypodermic  needle,  lancing  of  abscesses  and  ex- 
traction of  teeth.  The  anaesthetic  effect  is  brought  about  by 
superoxidization  within  the  tissues  caused  by  charging  the 
blood  with  an  abundance  of  oxygen. 

This  method  is  employed  by  instructing  the  patient  to  take 


98  ESSENTIALS  OF  OPERATIVE  DENTISTRY 

deep,  long  breaths  as  rapidly  as  possible  and  continue  the  same 
until  a  sense  of  dizziness  is  brought  on,  when  from  thirty  to 
sixty  seconds  of  the  anaesthetized  condition  will  be  found 
available  for  operating. 

Fifth. 

The  mechanical  conditions  under  which  the  cutting  of  den- 
tine is  done  is  a  great  factor  in  the  amount  of  pain  produced. 

Sharp  instruments  which  cut  without  pressure  upon  the  con- 
tents of  the  tubli  cause  much  less  pain  than  dull  ones  even 
with  hand  instruments.  With  rapidly  revolving  engine  burs 
this  is  also  true  to  say  nothing  of  the  heat  produced  by  the 
friction  caused  by  rubbing  surfaces  which  are  worn  away  rath- 
er than  cut,  which  is  the  chief  source  of  pain  in  the  use  of  burs. 

The  cutting  should  be  done  as  much  as  possible  at  a  right 
angle  to  the  long  axis  of  the  tubules  rather  than  to  follow  their 
course  with  pressure  towards  the  pulp  or  in  a  line  with  their 
long  axis. 


PROTECTION  OF  THE  VITAL  PULP  99 


CHAPTER    XVII. 

Protection  of  the  Vital  Pulp. 

The  normal  pulp  has  no  tactile  sense,  neither  is  it  responsive 
to  thermal  changes  even  though  they  vary  considerably  from 
the  body  temperature. 

When  robbed  of  its  normal  covering  and  protection  the  re- 
verse of  the  above  conditions  quickly  develop.  The  sense  of 
touch  becomes  very  acute  and  any  contact  with  foreign  sub- 
stances causes  great  pain.  This  is  best  illustrated  when  a  tooth 
is  broken  through  its  crown  by  a  blow,  thus  exposing  the  pulp. 
At  first  the  pulp  may  be  touched  with  the  finger  or  an  instru- 
ment without  the  knowledge  of  the  patient  but  in  a  very  few 
minutes  the  same  will  cause  unbearable  pain.  Also  at  first  the 
cold  air  does  not  affect  the  pulp,  but,  coincident  with  the  de- 
velopment of  the  tactile  sense,  comes  a  repugnance  to  the  cold. 

The  chief  idiosyncrasy  of  the  pulp  is  its  response  to  thermal 
changes  and  especially  to  cold,  when  these  changes  are  rapid 
or  the  pulp  is  in  any  way  hyperaemic.  A  normal  pulp  will  tol- 
erate without  response  quite  a  range  of  temperature  when  the 
change  is  brought  about  slowly.  This  is  generally  the  case 
when  the  pulp  is  covered  with  the  full  crown  of  the  tooth.  But 
when,  through  decay  or  other  causes,  this  covering  is  all  or 
partially  lost,  the  changes  are  so  rapid  that  the  peculiar  re- 
sponsive features  spoken  of  are  developed. 

The  recuperative  powers  of  the  pulp  are  very  slight,  the  least 
of  the  soft  tissues  of  the  body,  as  it  will  regain  a  healthy  con- 
dition from  only  the  initial  stages  of  disease.  It  will  many 
times  make  a  feeble  effort  to  protect  itself  when  the  irritation 
is  mild  by  filling  up  the  dental  tubuli  with  calcic  matter  or  a 
secondary  construction  of  dentine,  through  the  activity  of  its 
odontoblastic  layer  of  cells.  Even  this  reparative  process 
must  not  be  vigorously  inaugurated  or  the  death  of  the  pulp 


100  ESSENTIALS  OF  OPERATIVE  DENTISTRY 

will  result,  proving  that  these  reparative  measures  on  the  part 
of  the  pulp  are  pathological,  rather  than  physiological  in  na- 
ture. 

The  protection  of  the  pulp  from  its  greatest  enemy,  sudden 
thermal  changes,  is  most  essential  and  as  most  of  our  de- 
sirable filling  materials  are  good  conductors  of  heat  and  cold  it 
becomes  necessary  to  place  some  substance  whicii  is  a  poor 
conductor,  between  the  filling  and  the  dentine,  this  operation 
being  termed  "capping  the  pulp." 

The  indications  for  pulp  protection  are  not  always  clear,  but 
will  involve  a  consideration  of  the  age  of  the  patient,  extent  of 
loss  of  dentine,  location  of  the  cavity  in  the  tooth,  location  in 
the  mouth,  length  of  time  the  pulp  has  been  exposed,  the  stage 
of  hyperaemia,  the  general  health  of  the  patient  and  the  possi- 
bilities of  pulp  infection. 

The  age  of  the  patient  has  a  bearing  on  the  successful  issue 
of  a  conservative  treatment,  as  the  teeth  of  the  young  are  more 
easily  saved  from  further  irritation  through  capping  than  are 
the  teeth  of  those  past  middle  age,  while  at  the  same  time  they 
demand  capping  more  frequently  under  the  same  conditions. 
Again,  the  pulp  should  be  saved  if  possible  until  the  teeth  are 
fully  formed,  and  many  times  the  teeth  of  the  younger  patients 
are  badly  decayed  and  the  pulp  in  great  danger  before  the  teeth 
are  complete,  hence  if  the  pulp  can  be  conserved  and  devitali- 
zation avoided,  it  is  of  great  good  to  the  patient. 

In  advanced  age  the  apical  openings  become  smaller  and 
many  become  much  contracted  barely  accom.modating  the  ves- 
sels with  a  normal  flow  of  blood  so  that  a  very  slight  conges- 
tion may  cause  death  from  strangulation  or  gangrene. 

When  a  large  amount  of  dentine  has  been  lost,  e\'en  though 
the  pulp  as  yet  seems  normal,  it  is  safe  practice  to  avoid  the 
placing  of  the  best  conductors,  as  gold  or  amalgam,  in  close 
proximity  to  the  pulp  as  repeated  shocks  to  the  pulp  through 
the  filling  from  thermal  changes  may  bring  on  hyperaemia  of 
that  organ.  In  the  use  of  phosphate  of  zinc  cement  in  such 
cases,  there  should  be  an  intervening  media  to  prevent  the  ir- 
ritating effect  of  phosphoric  acid. 


PROTECTION  OF  THE  VITAL  PULP  101 

The  location  of  the  cavity  is  a  factor  in  the  demands  for  pulp 
protection,  as  well  as  the  probability  of  success  in  extreme 
coses.  The  first  portions  of  the  pulp  to  show  hyperaemic  con- 
ditions are  those  nearest  to  the  point  of  irritation.  These  con- 
gestions are  more  dangerous  when  they  appear  in  the  body  of 
the  pulp,  as  they  do,  where  decay  approaches  the  pulp  in  the 
gingival  third.  Hence,  when  a  pulp  is  nearly  exposed  in  this 
location  it  demands  greater  protection  and  is  at  the  same  time 
harder  to  save  than  when  the  horns  of  the  pulp  are  involved. 

The  location  of  the  tooth  should  be  considered.  Anterior 
teeth  are  subject  to  greater  extremes  of  heat  and  cold  than  are 
the  molars,  hence  the  demand  for  preventative  protection  with 
the  anterior  teeth  should  be  remembered.  At  the  same  time 
their  exposed  position  makes  pulp-capping  more  hazardous  and 
it  should  be  practiced  with  great  care  in  this  location.  Again, 
less  risk  should  be  taken  in  the  capping  of  pulps  in  the  anterior 
portion  of  the  mouth  as  it  is  better  to  remove  a  number  of 
questionable  pulps  than  to  have  one  die  in  the  tooth  with  its 
consequent  discoloration. 

The  length  of  time  the  pulp  has  been  exposed  to  the  irritat- 
ing influences  is  to  be  taken  into  account  as  the  shorter  the 
tvi.e  of  exposure,  the  greater  the  probabilities  of  success  in 
capping. 

The  stage  of  hyperaemia  should  be  a  safe  criterion  where 
there  are  actual  pulp  complications,  as  there  will  be  in  almost 
every  deep  seated  cavity.  In  active  hyperaemia,  from  causes 
other  than  bacteria,  it  is  safe  to  protect  the  pulp  from  future 
irritation  and  prognosticate  its  conservation.  However,  when 
the  symptoms  of  passive  hyperaemia  have  devoloped  it  is  not 
safe  practice  to  attempt  to  restore  the  pulp  to  normal  and  ex- 
pect permanency. 

The  symptoms  of  active  hyperaemia  when  the  pulp  demands 
protection  and  success  may  be  expected  are : 

First — When  the  excavated  cavity  exposed  to  the  air  causes 
a  continued  pain  not  of  a  throbbing  nature  and  the  condition 
is  relieved  by  packing  the  cavity  with  dry  cotton. 

Second — When  a  blast  of  air  from  the  chip  blower  causes  a 


102  ESSENTIALS  OF  OPERATIVE  DENTISTRY 

<.]uick,  sharp,  shooting  pain  which  subsides  as  quickly  as  it 
came. 

Third — When  the  pulp  shows  the  power  of  accommodation 
as  evidenced  by  tolerating  a  draft  of  cold  air  when  the  same  is 
gradually  applied. 

Fourth — When  it  is  improbable  that  the  pulp  has  become  in- 
fected. 

Pulps  infected  with  bacteria  should  be  extirpated  as  too  large 
a  per  cent  of  those  exposed  and  capped  die  and  thereby  bring 
reproach  upon  dentistry  in  general  and  chagrin  to  the  care- 
ful operator. 

The  time  was  when  the  profession  attempted  to  conserve 
all  portions  of  the  pulp  found  to  be  vital,  even  to  amputating 
the  coronal  portion  and  leaving  intact  the  vital  stumps.  How- 
ever, this  was  in  the  days  of  imperfect  root  canal  treatment 
and  filling  and  about  as  many  abscesses  followed  one  kind  of 
treatment  as  the  other.  But  at  the  present  time  the  removal 
of  a  pulp  is  attended  with  such  universal  success  that  the 
capping  of  exposed  pulps,  in  general,  is  unwarranted,  as 
most  pulps  are  infected  at  the  time  of  exposure.  Even  in 
the  case  of  an  accidental  exposure  in  the  preparation  of  a 
cavity  neither  cavity  nor  instruments  are  surgically  sterile. 

The  general  health  of  the  patient  must  be  considered  when 
choosing  betAveen  the  conservative  or  radical  treatment  of  the 
pulp.  AVith  the  same  conditions  presented,  the  pulps  in  the 
teeth  of  the  anaemic  patient,  those  wherein  the  vital  processes 
are  at  low  ebb,  or  the  illimination  of  the  vital  ash  is  imperfect 
and  cell  metabolism  is  deficient,  protective  means  of  conserva- 
tion are  more  imperative,  while  at  the  same  time  less  risk 
should  be  taken  in  questionable  cases. 

With  robust  and  particularly  plethoric  patients,  all  inflam- 
matory processes  run  a  rapid  and  riotous  course,  and  when 
the  pulp  has  taken  on  any  stage  of  hyperaemia  changes  to- 
wards dissolution  are  of  rapid  succession. 

In  deep  seated  cavities  it  is  not  unlikely  that  the  thin  layer 
of  the  dentine  covering  the  pulp  is  infected  and  the  pulp  should 


PROTECTION  OF  THE  VITAL  PULP  103 

be  protected  from  the  invasion  by  the  thorough  disinfection  of 
the  overlying  dentine  by  medication,  previous  to  filling  as  well 
as  placing  next  to  the  dentine  in  question  and  under  the  filling 
a  permanent  dressing  which  will  exert  a  mildly  antiseptic  in- 
fluence for  some  time  following  the  operation. 

The  requirements  of  the  materials  used  in  protective  pro- 
cedures are : 

First — That  they  shall  be  poor  conductors  of  heat  and  cold. 

Second — That  they  shall  be  non-changing  in  character,  both 
as  to  consistency  and  bulk. 

Third — That  they  have  no  action  upon  the  pulp. 

Fourth — That  they  may  be  introduced  into  deep  seated  cavi- 
ties without  pressure. 

The  materials  advocated  for  this  purpose  are  numerous  and 
the  market  is  flooded  with  preparations  of  a  secret  nature 
which  are  warranted  to  sa\e  the  pulp  in  almost  any  stage  of 
dissolution,  but  the  operator  who  pins  his  faith  to  such  slip- 
shod methods  will  sooner  or  later  find  that  he  has  been  duped 
and  his  grief  is  measured  by  the  extent  to  which  he  has  em- 
ployed these  cure-all  methods. 

There  are  four  distinct  classifications  wherein  success  may 
be  expected  in  methods  of  pulp  protection.  The  treatment  of 
each  class  is  here  given. 

First  Class.  In  the  progressive  stage  of  caries  wherein  but 
little  dentine  has  been  lost,  yet  a  blast  of  air  from  the  chip- 
blower  causes  a  quick,  sharp  pain  passing  off  as  soon  as  the 
draft  of  air  is  checked,  we  find  the  simplest  form  demanding 
protective  measures.  This  is  the  class  most  often  neglected  by 
the  operator  and  many  times  irreparable  injury  is  done  a  pulp 
by  placing  in  such  a  cavity  a  filling  of  high  conductivity,  such 
as  gold  or  amalgam.  The  patient  often  believes  that  "cold 
water  leaks  in  about  the  filling"  and  may  visit  another  dentist 
thinking  that  they  have  a  poor  piece  of  dentistry,  and  the  pa- 
tient may  be  lost  to  an  otherwise  good  operator,  all  through 
the  neglect  of  what  may  appear  to  the  operator  as  a  trivial  mat- 
ter. 


104  ESSENTIALS  OF  OPERATIVE  DENTISTRY 

The  treatment  in  this  first  class  is  the  thorough  disinfec- 
tion and  then  the  appHcation  of  phenol,  full  strength,  for  a 
few  seconds,  when  the  cavity  should  be  dried  and  it  will  be 
found  unafi;ected  by  the  blast  of  air  from  the  chip  blower. 
The  change  is  brought  about  by  the  superficial  coagulation 
of  the  albumen  in  the  exposed  ends  of  the  dental  tubuli  which 
renders  them  non-conductive. 

Second  Class.  If,  after  one  or  two  applications  of  the  phe- 
nol as  above,  the  distress  from  the  blast  of  air  is  not  relieved, 
or  if  the  pain  is  continuous  while  the  surface  of  the  cavity 
is  exposed  to  the  air  it  is  probably  of  the  second  class  as 
met  with  in  the  nearer  approaches  to  the  pulp.  This  class 
of  cases  demands  a  media  intervening  the  dentine  and  the 
filling. 

The  treatment  in  the  second  class  is  as  follows:  Moisten 
the  cavity  with  phenol  and  evaporate  to  comparative  dry- 
ness. Then  paint  the  entire  dentinal  walls  with  a  cavity  var- 
nish composed  of  copal  and  gum  demahr  in  alcohol  and  ether 
solution.  Such  a  preparation  can  be  had  at  the  dental  depots 
or  it  can  be  prepared  by  the  druggist.  This  should  be  thin 
and  spread  evenly,  applying  one,  two  or  three  coats  and  dry- 
ing with  a  draft  of  air  from  the  chip  blower  after  each  coat. 
When  entirely  hardened  the  filling  may  be  placed. 

Third  Class.  In  the  deep-seated  stage  of  caries,  where  large 
quantities  of  dentine  have  been  lost,  even  though  the  pulps 
may  seem  to  be  protected  by  secondary  dentine  and  is  much 
retracted,  it  is  not  safe  to  place  a  metal  filling  directly  on  the 
overlying  dentine.  The  lost  tooth  structure  should  in  a  meas- 
ure be  replaced  with  a  material  which  is  no  greater  conductor 
of  heat  and  cold  than  the  dentine.  This  should  be  neutral 
as  far  as  irritating  properties  are  concerned,  non-changing 
and  should  resist  the  force  necessary  to  properly  introduce 
the  intended  filling. 

The  treatment  in  this  third  class  is  as  follows :  Phenolize 
and  dry.  Varnish  with  the  above  cavity  varnish  and  dry. 
Flow  over  the  dentine,  covering  most  if  not  all  of  the  axial 
or  pulpal  wall,  or  both,  according  to  the  class  of  cavity  being 


PROTECTION  OF  THE  VITAL  PULP  lOo 

treated,  a  thin  layer  of  oxyphosphate  of  zinc  cement,  being 
careful  not  to  include  thereunder  any  air  bubbles;  also  ap- 
ply without  pressure.  Then  allow  this  to  set  to  complete 
hardness,  when  the  filling  may  be  completed.  In  the  three 
classes  given  above  it  will  be  noted  that  coagulation  of  the 
protoplasm  in  the  exposed  ends  of  the  tubuli  was  the  first 
step.  This  is  good  practice  from  the  fact  that  this  layer  of 
coagulum  is  the  least  irritant  to  the  remaining  protoplasm  of 
anything  of  which  we  have  knowledge.  Phenol  is  very  lim- 
ited in  the  extent  of  its  action  and  this  layer  of  coagulation  is 
very  thin.  Again,  with  this  third  class,  it  will  be  noted  that 
in  addition  to  the  use  of  the  phenol  the  cavity  is  given  a 
coat  of  varnish  before  applying  the  oxyphosphate  of  zinc 
cement.  This  procedure  is  to  prevent  the  irritating  effects  of 
the  phosphoric  acid,  particularly  while  the  cement  is  setting. 
Again,  should  the  zinc  contain  any  impurities  their  action  on 
the  pulp  is  prevented.  One  of  the  impurities  of  zinc  is  arsenic 
and  some  cements  are  thought  to  contain  traces  of  this  de- 
vitalizing agent.  The  cavity  varnish  given  above  is  quite 
impervious  to  this  element  when  it  has  been  thoroughly  hard- 
ened, a  fact  which  should  not  be  overlooked  when  it  is  de- 
sired to  prevent  the  action  of  arsenic  trioxide  in  a  particular 
direction  in  a  dental  wall. 

Fourth  Class.  In  deep-seated  cavities  where  there  is  a 
slight  pulp  complication  from  thermal  shock  and  where  the 
thin  overlying  layer  of  dentine  is  probably  infected  to  some 
depth  and  more  deeply  affected  in  the  process  of  caries,  the 
dentine  should  be  subjected  to  quite  a  continued  disinfecting 
process  while  at  the  same  time  restoring  a  portion  of  the  lost 
dentine  with  a  non-conducting  material  to  shield  the  pulp 
from  sudden  thermal  changes. 

The  treatment  in  the  fourth  class  of  cases  is  as  follows :  The 
cavity  should  be  flooded  with  a  non-irritating  antiseptic,  as 
campho-phenique,  pure  beech-wood  creosote  or  oil  of  cloves. 
If  sealed  in  the  cavity  for  twenty-four  hours  the  result  will 
be  much  better.  The  cavity  should  be  then  wiped  dry  with 
absorbent  cotton  and  a  thin  paste  of  the  oxide  of  zinc  and  oil 


106  ESSENTIALS  OF  OPERATIVE  DENTISTRY 

of  cloves  spread  over  the  dentine  overlying-  the  pulp.  This 
paste  should  be  thin  enough  to  flow  to  position  when  coaxed 
with  a  small  instrument,  yet  thick  enough  to  prevent  its 
spreading  to  surfaces  not  needed.  Over  this  spread  a  layer  of 
oxyphosphate  of  zinc  cement  and  allow  this  to  set  hard  be- 
fore completing  the  filling. 

In  very  questionable  cases,  the  entire  cavity  may  be  com- 
pleted with  the  cement  and  the  patient  dismissed  for  six 
months  at  the  end  of  which  time,  if  the  pulp  is  found  to  be 
normal,  a  portion  of  the  cement  may  be  removed  and  re- 
placed with  a  more  permanent  material. 

Pulp  preservers  and  so-called  mummifiers  should  be  avoided. 
Even  their  name  is  misleading  and  such  preparations  are  used 
without  permanent  success  in  the  majority  of  cases.  Their 
use  simply  proclaims  their  users  as  unskilled  laggards  who 
will  accept  an  uncertainty  to  avoid  a  little  honest  labor  in 
pulp  extirpation  and  root  filling.  The  entire  procedure  is  dia- 
bolical and  can  not  be  condemned  in  too  severe  terms  as  a 
retrogression  in  dentistry,  unskilled  in  principle  and  unwar- 
ranted in  practice.  Gutta-percha  as  a  protecting  covering  is 
not  a  success  from  the  fact  of  its  great  range  of  contraction 
and  expansion  under  varying  thermal  changes.  When  en- 
closed under  a  perfectly  tight  and  unyielding  filling,  as  all 
fillings  should  be,  the  change  in  bulk  must  have  a  pistolic 
effect  upon  the  contents  of  the  dental  tubuli  resulting  in  con- 
tinned  irritation. 


PULP  DEVITALIZATION  AND  REMOVAL  107 


CHAPTER   XVIII. 

Pulp  Devitalization  and  Removal. 

The  reason  for  devitalization  and  removal  of  a  pulp  is  its 
present  unhealthy  condition  or  when  its  future  health  is  in 
danger,  on  account  of  environment  in  the  way  of  dental  opera- 
tions. 

There  are  two  general  causes  of  diseased  pulps : 

First.  That  succession  of  tissue  changes  which  has  its 
origin  in  active  hyperaemia  and  its  end  in  death  due  to  the 
presence  of  bacteria  or  their  products — inflammation. 

Second.  Reparative  congestion,  due  to  traumatic  injury, 
abnormal  thermal  stimuli,  lack  of  normal  thermal  stimuli  and 
periphoral  nerve  irritation. 

Bacteria  and  their  products  may  enter  the  pulp  tissue  either 
through  a  loss  of  its  normal  covering,  the  dentine,  as  in  the 
case  of  deep-seated  caries,  or  through  the  general  circulation 
by  way  of  the  apical  foramen,  as  in  pyorrhea  alveolaris,  or  in 
other  pus  conditions  in  close  proximity  to  the  pulp  vessels. 
We  have  no  means  of  knowing  that  a  pulp  thus  invaded  has 
recovered,  while  we  have  complete  proof  of  their  subsequent 
death  from  this  cause,  hence  devitalization  is  indicated  as 
soon  as  diagnosis  is  clear. 

The  removal  of  the  cause  in  reparative  congestion  of  the 
pulp  will  generally  suffice  to  save  the  pulp  from  further  de- 
struction provided  the  intervention  is  in  the  stage  of  active 
hyperaemia. 

The  traumatic  injuries  most  common  in  the  production  of 
pulp  congestion  are  blows  upon  the  teeth  either  through  acci- 
dent or  excessive  malleting  in  dental  operations;  rapid  move- 
ment by  the  orthodontist ;  abnormal  stress  in  occlusion  or  ar- 
ticulation ;    mal-occlusion    and    abnormal    movement    of    the 


108  ESSENTIALS  OF  OPERATIVE  DENTISTRY 

tooth  in  its  ah'eolus  made  possible  by  the  loss  of  supporting 
structures. 

Abnormal  thermal  stimuli  is  a  most  potent  factor  in  pro- 
ducing pulp  congestion.  The  pulp  is  particularly  and  pe- 
culiarly susceptible  to  thermol  changes  and  this  idiosyn- 
crasy is  very  rapidly  magnified  as  the  stages  of  congestion 
progress. 

The  reason  for  abnormal  thermal  changes  reaching  the  pulp 
is  the  loss  of  its  natural  covering,  the  dentine  and  enamel, 
through  caries,  erosion,  abrasion  or  dental  operations  as  well 
as  the  denuding  of  the  root  by  a  recession  or  loss  of  the  sub- 
gingival structures. 

Lack  of  normal  thermal  stimuli  will  induce  a  stagnated  cir- 
culation with  a  sequella  of  degenerative  changes  within  the 
pulp  tissues,  resulting,  many  times,  in  the  death  of  that  or- 
gan. While  the  pulp  is  profoundly  affected  by  abnormal  ex- 
posure to  heat  and  cold  it  is  eminently  essential  to  its  normal 
physiological  existence  that  it  receive  the  stimulating  effects  of 
the  ranges  of  temperature  usually  found  in  food  and  drink 
while  covered  with  the  entire  tooth. 

Peripheral  nerve  irritation  may  bring  about  reparative  con- 
gestion within  the  pulp  causing  excessive  tissue  waste  and  a 
precipitation  of  lime  salts  within  the  pulp.  There  are  two 
classes  of  these  deposits  known  as  calcific  degeneration  and 
pulp  nodules,  the  latter  being  the  sequella  of  peripheral  nerve 
irritation,  Avhiie  calcific  degeneration  is  the  result  o.*^  little 
local  passive  hyperaemias  with  its  cause  related  to  abnormal 
thermal  changes. 

The  irritation  may  be  to  the  terminal  fibers  of  the  nerves 
within  the  pulp  where  the  nodules  are  found,  or  in  an  ap- 
proximating tooth,  or  in  a  tooth  in  the  same  lateral  half  of  the 
jaw  or  face.  Cases  are  reported  where  it  is  evident  that  the 
cause  is  even  more  remote  than  has  been  stated,  it  being  a 
local  expression  of  a  general  neurotic  condition. 

The  requirements  of  a  devitalizing  agent  are : 

First.  That  the  present  and  future  health  of  adjacent  tis- 
sues be  maintained. 


PULP  DEVITALIZATION  AND  REMOVAL  JO'J 

Second.     That  it  act  painlessly. 

Third.     That  the  dentine  is  not  discolored. 

Fourth.  That  devitalization  be  accomplished  promptly,  re- 
sulting in  a  saving  of  time  to  both  the  patient  and  operator. 

The  methods  of  pulp  devitalization  practiced  at  this  time 
are  two :  Surgical  amputation  while  anesthetized  and  poison- 
ing by  the  application  of  arsenic  trioxide. 

To  determine  the  method  to  employ  in  any  given  case  re- 
quires an  understanding  of  the  pulp  presented,  its  immediate 
surroundings,  and  results  sought.  Also  the  time  at  the  dis- 
posal of  patient  and  operator.  While  each  of  the  two  meth- 
ods has  its  advantages,  either  can  be  so  used  as  to  meet  the 
requirements  of  a  satisfactory  means  of  devitalization. 

Anesthetization  of  the  pulp  is  accomplished  by  forcing  into 
the  pulp  a  solution  of  cocaine  hydrochloride,  popularly  known 
as  "pressure  anesthesia." 

Anesthetization  is  indicated: 

First.     Where  it  is  desired  to  remove  a  normal  pulp. 

Second.  When  slight  exposure  of  the  pulp  exists  which  has 
not  yet  reached  the  stage  of  passive  hyperaemia. 

Third.  Pulps  whose  circulatory  system  is  active,  but  whose 
nervous  system  is  either  deficient  in  development  or  is  in  the 
stages  of  neuro-paralysis.  Access  to  the  tooth  is  a  factor  to 
be  considered  and  will  result  in  the  more  frequent  use  of  this 
method  with  the  anterior  teeth.  The  possibility  of  securing  a 
sterile  field  of  operation  must  be  considered  as  an  advantage. 

The  technic  of  the  operation  where  a  cavity  exists  is  as  fol- 
lows :  Apply  the  rubber  dam.  Excavate  the  affected  dentine. 
Sterilize  the  remaining  cavity.  Place  in  the  cavity  over  the 
pulp  a  small  pellet  of  cotton  saturated  with  the  following: 

Cocaine  hydrochloride,  one-sixth  grain. 

Adrenalin  chloride,  one  gtt. 

Apply  over  this  a  piece  of  unvulcanizcd  rubber  which  will 
approximately  fill  the  cavity  and  with  blunt  instruments,  as 
amalgam  packers,  gently  force  the  mass  in  tlic  direction  of 
the  ynilp.     It  is  essential  that  the  nil)l)cr  first  come  into  con- 


110  ESSENTIALS  OF  OPERATIVE  DENTISTRY 

tact  with  the  cavity  margins  at  all  points,  or  the  fluid  will  not 
be  confined  and  its  escape  renders  the  attempt  a  failure.  If 
the  first  pressure  of  the  confined  solution  upon  the  pulp  causes 
pain  the  operator  should  stop  increasing  the  pressure,  but  hold 
the  advantage  gained  by  not  releasing  the  pressure  already 
applied,  when,  after  waiting  a  minute  or  two,  the  pressure 
may  be  increased  and  finally  the  rubber  can  be  kneaded  into 
the  cavity  with  considerable  force.  Sometimes  one  applica- 
tion thus  made  will  completely  anesthetize  a  pulp.  However, 
other  cases  will  require  two  or  more  applications.  Between 
such  applications  the  dentine  should  be  removed  from  over 
the  pulp  to  complete  exposure  where  this  can  be  done  with- 
out undue  pain  to  the  patient. 

When,  after  two  or  three  attempts  of  the  above  method 
there  seems  to  be  no  effect  obtained,  it  is  generally  best  for 
both  patient  and  operator  to  resort  to  the  application  of  ar- 
senic, unless  the  case  is  suited  to  favor  the  use  of  the  high 
pressure  syringe. 

The  high  pressure  syringe  is  of  service  where  no  exposure 
exists,  and  where  the  necessary  puncture  for  the  introduction 
of  the  syringe  point  can  be  included  in  the  filling,  or  where 
the  crown  is  to  give  place  to  an  artificial  one  as  an  abutment 
for  a  bridge.  The  method  has  to  recommend  it  speed,  a  cer- 
tainy  of  preserving  the  color  and  is  generally  accomplished 
with  little  or  no  pain  to  the  patient. 

The  Technic  in  Its  Use.  To  the  prescription  given  for  the 
open  cavity  add  fifteen  drops  of  distilled  water  and  load  the 
syringe,  seeing  that  all  joints  are  screwed  up  tight.  Select  a 
point  of  direct  access  either  on  the  dentinal  walls  or  it  may 
be  on  the  external  enamel  surface,  preferably  in  the  gingival 
third  of  the  tooth,  and  drill  a  hole  directly  towards  the  pulp 
one  millimeter  in  depth  and  as  much  farther  as  possible  with- 
out causing  the  patient  pain.  The  drill  used  should  be  smaller 
than  the  syringe  point  that  a  close  fit  to  the  hole  may  be 
secured.  Syringes  are  generally  constructed  so  that  a  drill 
made  by  flattening  a  No.  1-2  round  bur  will  make  a  proper 
sized  hole.  The  syringe  is  then  applied  to  the  opening  with 
some  pressure  and  its  contents  forced  into  the  dentine. 


PULP  DEVITALIZATION  AND  REMOVAL  111 

It  is  essential  that  the  solution  be  perfectly  imprisoned  as  it 
requires  high  pressure  to  force  the  anesthetic  through  the 
tubuli.  After  holding  the  solution  at  high  pressure  in  contact 
with  the  dentine  for  one  or  two  minutes  it  should  be  removed 
and  the  drill  applied  to  the  hole  to  test  its  sensibility.  If 
desensitized  the  hole  should  be  carried  close  to  the  pulp  but 
not  so  far  as  to  enter  the  chamber.  The  syringe  should  be 
again  applied  and  with  great  care,  as  sudden  force  may  cause 
pain  by  too  rapid  pressure  upon  the  pulp. 

Great  Care  should  be  exercised  when  the  pulp  has  been  thus 
nearly  or  quite  exposed  not  to  force  into  the  pulp  any  con- 
siderable amount  of  anesthetic  as  it  is  carried  or  forced  be- 
yond the  apical  foramen,  from  which  no  good  can  result  and 
may  do  harm,  particularly  if  the  contents  of  an  infected  pulp 
is  forced  through  to  the  tissues  of  the  pericementum. 

Pulp  extirpation  by  hypodermic  injection.  Pulps  may  be  re- 
moved very  quickly  and  with  little  pain  by  injecting  the  peri- 
dental membrane  with  the  solution  of  cocaine  given  for  use  in 
extracting  teeth  in  Chapter  XXI. 

The  tissues  should  be  thoroughly  sterilized.  The  needle 
should  be  small,  about  29  g.  and  entered  as  far  root  wise  as  pos- 
sible between  cementum  and  alveolar  process  and  injected 
with  considerable  pressure. 

If  correctly  done  the  pulp  may  be  removed  or  the  tooth  ex- 
tracted painlessly.  Extreme  care  as  to  asepsis  must  be  given 
as  case  will  return  with  diseased  peridental  membrane  in  pro- 
portion to  the  amount  of  infection.  This  danger  of  infection 
makes  this  method  unsuited  for  general  use,  but  applicable  to 
cases  where  haste  is  imperative  or  where  trouble  is  experienced 
in  the  use  of  pressure  anesthesia  or  arsenic  dcvilatization. 

The  removal  of  an  anesthetized  pulp  is  accomplished  by 
gaining  access  to  the  pulp  chamber  from  a  position  which  will 
admit  of  direct  or  nearly  direct  approach  to  each  of  the  root 
canals,  and  making  the  opening  large  enough  to  admit  light 
enough  to  see  either  by  direct  vision  or  the  image  in  the  mir- 
ror, the  entire  floor  of  the  chamber.  First,  a  smooth  sterile 
broach  is  passed  down  each  canal  to  the  apex  of  the  root,  to 


112  ESSENTIALS  OF  OPERATIVE  DENTISTRY 

test  the  completeness  of  the  anesthetization.  If  no  sensation 
is  found  the  barbed  broach  is  then  passed  to  the  apex,  pre- 
ferably an  extra  fine  size.  This  should  be  twisted  to  the  right 
about  one  complete  turn  and  then  gently  drawn  from  the  cav- 
ity, which  should  result  in  the  amputation  and  removal  of  the 
entire  pulp.  This  accomplished,  the  sides  of  the  canal  should 
be  rasped  with  a  barbed  broach  of  a  larger  size  to  remove  any 
shreds  which  may  adhere  to  the  sides  of  the  canals. 

To  check  hemorrhage  should  that  ensue,  wash  the  chamber 
and  canals  with  cold  water,  dry  as  quickly  as  possible,  flood 
cavity  with  a  drop  of  adrenalin  chloride  and  apply  a  plug  of 
dental  rubber,  pressing  this  into  the  cavity  and  holding  it  for 
a  few  minutes.  Remove  the  rubber  and  wash  again  with  cold 
water.  If  hemorrhage  continues  repeat  holding  the  adrenalin 
confined  longer  than  before  and  applying  a  little  more  force. 
Care  should  be  used  in  this  procedure  as  a  sore  tooth  will  re- 
sult when  the  method  has  been  used  too  vigorously.  Again 
thoroughly  bathe  the  canals  with  cold  water  or  alcohol  and 
dry. 

Discoloration  results  from  allowing  any  blood  to  remain  in 
contact  with  the  dentine,  even  though  it  be  only  from  one 
treatment  to  another  as  the  iron  of  the  hemoglobin  is  ab- 
sorbed or  forced  into  the  tubuli  resulting  in  permanent  dis- 
coloration. The  use  of  hydrogen  dioxide  is  not  good  practice 
until  the  blood  has  been  washed  from  the  dentinal  walls  as 
it  oxidizes  the  iron  of  the  hemoglobin  and  will  also  result  in 
discoloration. 

Post-extirpation  pains  may  be  prevented  by  pumping  into 
the  canals  phenol  with  a  smooth  broach  continuing  this  until 
the  nerve  stump  at  the  foramen  is  bathed  with  this  agent.  This 
also  has  the  effect  of  coagulating  the  mouths  of  the  dental 
/^  tubuli,  resulting  in  sealing  them  to  agents  which  may  Cause 

discoloration. 

It  is  the  best  practice  to  dress  the  root  for  a  few  days  with  a 
stimulating  anodyne  which  is  at  least  mildly  antiseptic  as  the 
anesthetizing  of  the  pulp  has  probably  so  much  affected  the 
tissues  in  the  apical  space  that  there  is  nothing  to  guide  us 
in  properly  falling  the  root  canals. 


PULP  DEVITALIZATION'  AND  REMOVAL  118 

Immediate  root  filling  in  these  cases  is  sometimes  prac- 
ticed where  lack  of  time  demands  a  hurried  completion  of  the 
case  and  is  quite  successfully  accomplished  where  all  is  just 
right.  But  so  many  times  ideal  conditions  for  root  filling  are 
not  obtainable  that  its  universal  practice  is  condemned.  How- 
ever, if  there  is  to  be  immediate  root  filling,  the  root  canals 
should  be  bathed  with  water  and  dried  with  warm  air.  Flood- 
ed with  phenol  and  again  dried,  this  time  with  the  aid  of 
absolute  alcohol  when  the  root  filling  may  be  introduced  as 
outlined  in  the  chapter  on  "The  Filling  of  Root  Canals." 

Devitalization  with  arsenic  trioxide  is  the  method  in  most 
frequent  use  and  although  not  always  to  be  preferred  to  an- 
esthetization, it  may  be  used  in  almost  any  case  with  satis- 
factory results. 

Arsenic  should  be  combined  with  some  agent  to  allay  the 
pain  caused  by  its  application  as  it  is  a  most  powerful  eschar- 
otic  and  the  clear  arsenic  applied  to  a  pulp  will  many  times 
cause  great  pain.  One  of  the  most  popular  mixtures  is  here 
given : 

Arsenic    trioxide gr.  v. 

Cocaine    gr.  xv. 

Creosote  O.  S.  ft.  stiff  paste. 

To  this  should  be  added  enough  lamp  black  to  make  the 
above  a  dark  grey  color  so  that  it  will  be  a  contrasting  color 
with  that  of  the  tooth  to  assist  in  placing  it  in  the  exact 
location  desired. 

The  Technic  of  its  application  is  as  follows:  The  cavity 
should  be  thoroughly  protected  and  dried,  preferably  under 
the  rubber  dam.  .  Foreign  matter  should  be  removed  from 
the  cavity  and  the  same  thoroughly  sterilized,  the  softened 
dentine  removed  and  the  pulp  approached  to  as  near  exposure 
as  possible  without  causing  the  patient  pain.  Complete  ex- 
posure is  not  necessary.  Again  sterilize  the  cavity  and  dry. 
Bathe  cavity  with  phenol  and  again  dry.  With  the  enamel 
hatchets  secure  a  definite  cavity  margin,  j^articularly  if  cavity 
is  in  the  gingival  third.  In  cavities  that  arc  sub-gingival 
build  in  amalgam  as  high  as  the  gum  line  or  at  least  one  or 

(4) 


114  ESSENTIALS  OF  OPERATIVE  DENTISTRY 

two  millimeters  high,  being  sure  not  to  let  this  approach  the 
pulp  exposure  or  the  point  where  the  application  is  to  be 
made.  Take,  of  the  above  paste  on  the  point  of  a  flat  ex- 
cavator, a  quantity  equal  to  about  one-fourth  the  size  of  a 
common  pin  head  and  apply  very  close  to,  but  not  directly 
on  the  exposed  pulp.  By  very  close  is  meant  within  one-half 
millimeter.  Place  over  this  a  piece  of  spunk  the  size  of  a  pin 
head,  or  larger,  if  cavity  is  large  and  roomy,  which  has  been 
dipped  in  creosote  and  then  pinched  in  a  napkin  to  dryness 
putting  into  place  in  such  a  manner  as  not  to  cause  pressure 
on  the  pulp.  The  retaining  filling  may  now  be  completed 
with  amalgam,  cement  or  temporary  stopping. 

Amalgam  As  a  Retainer  of  arsenic  has  the  advantages  of 
making  a  tight  filling  at  the  margins.  Nothing  will  pass 
through  it  and  it  is  the  most  easily  removed  if  it  is  applied 
where  there  are  frail  overhanging  enamel  walls  which  a  chisel 
will  easily  cleave;  or  if  the  amalgam  has  been  but  partially 
mixed  with  not  enough  mercury,  resulting  in  a  mealy  filling 
or  where  a  great  excess  of  mercury  has  been  used — that  is  to 
say  where  a  most  poorly  manipulated  amalgam  has  been  used 
resulting  in  its  being  cut  with  a  bur  much  more  easily  than 
cement,  an  advantage  in  cases  where  a  tooth  becomes  sore  to 
percussion. 

Cement  As  a  Retainer  of  arsenic  has  the  advantage  of  set- 
ting quickly  thus  removing  the  danger,  in  occlusal  cavities, 
of  the  patients  causing  themselves  pain  by  biting  on  the  fill- 
ings producing  pressure  on  the  pulp.  With  anterior  teeth  it 
is  more  sightly  than  amalgam  or  stopping.  Its  only  disad- 
vantage is  that  it  sometimes  sets  so  well  that  it  is  hard  to 
remove  and  its  adhering  property  may  result  in  dragging  or 
lifting  the  application  from  its  placement,  during  the  manipu- 
lation of  introduction. 

Temporary  Stopping  As  a  Retainer  of  arsenic  has  to  recom- 
mend it  the  ease  of  its  removal  with  warmed  instruments  and 
especially  if  its  surface  has  been  treated  with  a  blast  of  warm 
air.  The  dangers  in  its  use  lie  in  the  difficulty  in  preventing 
pressure  upon  the  pulp  either  when  applied  or  in  mastication. 


PULP  DEVITALIZATION  AND  REMOVAL  115 

Cotton  As  a  Retainer  of  arsenic  should  be  entirely  discon- 
tinued as  it  has  nothing  to  recommend  it  and  everything  to 
condemn  it. 

Caution  in  the  Use  of  arsenic  about  the  teeth  is  of  great 
importance  and  when  used  it  must  be  sealed  in  the  dry  cavity 
absolutely  moisture  proof  and  particularly  when  any  of  the 
cavity  outline  is  sub-gingival  as  any  leakage  at  this  point  will 
result  in  great  destruction  to  the  gums  and  alveolar  process. 
Such  accidents  are  all  too  frequent  and  the  injury  thus  done 
is  never  fully  repaired. 

The  Length  of  Time  an  Arsenical  application  should  be  left 
in  the  tooth  is  most  uncertain  and  there  seems  to  be  no  set 
rule.  Neither  the  condition  of  the  pulp  nor  the  amount  of 
dentine  intervening  can  be  taken  as  certain  in  judging  the 
time.  However  it  is  most  common  practice  to  see  the  case 
in  about  one  week's  time,  as  in  this  time  a  majority  of  the 
cases  will  have  become  devitalized  and  the  natural  process 
of  exfoliation  has  taken  place  between  the  dead  pulp  and  the 
living  tissues  at  the  apex  of  the  root  enabling  the  operator 
to  remove  the  pulp  without  pain  or  hemorrhage. 

Primary  Soreness  of  the  Tooth  to  percussion  generally  in- 
dicates the  death  of  the  pulp.  If  an  attempt  is  made  to  re- 
move the  pulp  too  soon  great  pain  will  result  as  the  pulp  is 
yet  vital,  hence  it  is  best  to  wait  until  the  pulp  has  been  fully 
affected.  Again  during  the  primary  soreness  and  particu- 
larly during  the  first  twenty-four  hours  of  this  condition  the 
patient  cannot  tolerate  the  instrumentation  necessary.  Such 
cases  should  be  left  for  from  twenty-four  to  forty-eight  hours 
from  the  time  pericemental  soreness  develops,  having  applied 
to  the  gum  over  the  afflicted  tooth  aconite  and  iodine  when  it 
will  generally  permit  of  treatment. 

Secondary  Pericementitis  is  dangerous  to  the  sub-dental 
tissues  and  no  arsenical  application  should  be  allowed  to  re- 
main until  this  second  attack  appears,  as  the  loss  of  the  tooth 
is  not  ])eyond  the  possibilities  of  such  neglect. 

The  Treatment  of  Arsenical  Poisoning  due  to  its  escape 
from  the  cavity  is  as  follows  :     Remove  everything  from  the 


116  ESSENTIALS  OP  OPERATIVE  DENTISTRY 

tooth  cavity.  Flood  the  cavity  and  destroyed  tissues  with  a 
forceful  stream  of  tepid  water  to  remove  all  traces  of  the 
arsenic  not  yet  absorbed.  With  a  sterile  spoon  excavator 
dissect  and  curet  away  all  necrotic  tissue  continuing  until 
hemorrhage  is  produced.  Again  flood  the  parts  with  warm 
water.  Dry  with  a  cotton  ball  and  lightly  paint  the  wound 
with  aconite  and  iodine,  repeating  the  treatment  every  other 
day  until  a  healing  is  effected. 

When  Pulp  Returns  partially  devitalized  as  is  evidenced  by 
sensation,  particularly  in  the  apical  third  of  the  root,  it  is  best 
to  open  the  pulp  chamber  and  amputate  with  a  sharp  spoon 
excavator  only  the  coronal  portion.  Wash  chamber  out  with 
warm  water  and  dry  with  warm  air.  Apply  absolute  alcohol 
working  same  towards  the  apex  by  the  side  of  the  pulp  as 
far  as  possible  without  causing  pain,  following  this  with  thor- 
ough dessication  with  warm  air.  Then  seal  in  a  dressing  of 
phenol  and  dismiss  for  one  week  or  even  longer  and  the  case 
will  usually  return  with  devitalization  complete.  This  treat- 
ment is  particularly  indicated  in  young  teeth  where  the  apical 
foramen  is  large. 

The  Removal  of  the  Pulp  following  arsenical  devitalization 
is  practically  the  same  as  that  following  anesthetization,  ex- 
cept that  in  the  latter  case  there  is  danger  of  going  beyond 
the  apex,  while  with  arsenic  devitalization  method  the  greater 
danger  is  in  not  extirpating  the  pulp  entirely  to  the  apex 
.through  mistaking  a  vital  pulp  stump  within  the  canal  for 
vital  tissue  beyond. 

Immediate  Root  Filling  following  arsenical  devitalization  is 
quite  universally  practiced  and  is  generally  satisfactory,  how- 
ever, too  large  a  percent  is  followed  by  mild  or  severe  peri- 
cementitis, which  might  be  averted  by  dressing  the  canals 
with  a  mildly  antiseptic  anodyne  of  a  stimulating  nature  for  a 
few  days  before  falling  the  roots. 

All  Treatments  Above  Referred  to  in  this  chapter  should 
be  carried  out  with  the  rubber  dam  in  place  at  each  sitting. 
See  chapter  on  "The  filling  of  root  canals." 


MANAGEMENT  OF  PUTRESCENT  ROOT  CANALS  117 


CHAPTER  XIX 

Management   of  Putrescent  Root  Canals 

By  Putrescent  Root  Canals  is  meant  that  condition  in  these 
spaces  resulting  from  putrefaction. 

By  Putrefaction  is  Meant  that  serial,  progressive  decompo- 
sition through  which  albuminous  substances  are  finally  re- 
solved into  the  end-products,  hydrogen  sulfid.  (H^  S),  carbon 
dioxid,  (C  O^),  ammonia,  (N  H^),  water,  (H^  O)  and  hydro- 
gen phosphid,  (3  P  H^.)  A  distinguishing  feature  of  the  pro- 
cess is  the  evolution  of  malodorous  gases. 

The  Presence  of  Bacteria  is  necessary  to  the  process  of 
putrefaction  and  all  such  cases  must  be  approached  with  this 
fact  in  mind,  and  antiseptic  measures  and  precautions  are 
paramount  from  the  beginning  of  the  case  to  its  termination, 
that  the  pericementum  may  not  be  involved  in  the  destruc- 
tive process. 

There  Are  Four  Classes  of  Putrescent  root  canals,  accord- 
ing to  the  manner  in  which  they  are  presented,  symptoms 
present  and  the  method  of  treatment. 

First:  Those  cases  where  the  canals  are  open  and  exposed 
to  the  fluids  of  the  mouth  known  as  "open  putrescence"  and 
which  are  generally  the  result  of  the  encroachment  of  caries. 

Second:  Those  cases  wherein  the  pulps  die  under  a  filling, 
or  a  layer  of  affected  and  infected  dentine,  the  integrity  of 
which  will  not  permit  of  the  passage  of  fluids  or  gases.  This 
is  known  as  "closed  putrescence"  and  is  the  result  of  extrinsic 
infection. 

Third:  Those  cases  wherein  the  crown  is  integral  and  the 
bacteria  necessary  to  putrefaction  ha\Q  entered  the  pulp 
tissue  either  before  or  after  its  death  by  way  of  the  apical 
foramen,  conveyed  there  by  the  circulation  of  the  blood.  This 
class  of  cases,  from  the  apparent  autopathy  is  termed  "auto- 


118  ESSENTIALS  OF  OPERATIVE  DENTISTRY 

genous  putrescence."  Such  cases  are  most  likely  to  follow 
suppurative  processes  in  close  proximity  to  the  arteries  lead- 
ing to  the  pulp,  yet  cases  are  seen  where  no  such  conditions 
can  be  diagnosed,  primary  to  the  pulp  symptoms,  and  are 
generally  traumatic. 

Fourth:  Those  cases  wherein  the  destructive  processes  have 
been  communicated  to  the  pericementum,  and  are  known  as 
"complicated  putrescence."  There  may  be  pericemental  in- 
flammation in  any  of  its  stages  with  or  without  soreness  to 
percussion.  The  apical  space  may  harbor  pus  without  other 
communication  than  the  putrescent  root  canal  or  there  may 
be  an  abscess  with  a  fistula  passing  through  the  alveolar  pro- 
cess and  opening  in  the  gum. 

Treatment  in  General  may  be  stated  as  involving  the  re- 
moval by  mechanical  and  chemical  means,  all  products  of 
putrefaction.  Thorough  sterilization  of  all  surfaces  exposed, 
conservation  of  vital  tissues  beyond  the  apical  foramen  and 
the  permanent  closure  of  the  foramen  to  the  passage  of  fluids 
and  gases. 

The  Symptoms  of  Open  Putrescence  (class  one)  are  not 
marked  where  the  pulp  is  entirely  putrescent,  unless  there  are 
pericemental  complications,  when  the  case  would  come  under 
the  heading  of  complicated  putrescence.  When  a  portion  of 
the  pulp  is  yet  vital  it  is  probable  that  the  pulp  is  undergoing 
a  molecular  disintegration  through  surface  ulceration.  This 
is  usually  a  painless  process  and  is  responsive  only  to  the  en- 
croachment of  foreign  substances  which  lacerate  its  tissues  or 
produce  pressure  within  its  substance.  Such  cases  call  for 
sterilization  and  extirpation.  However,  with  simple  open 
putrescence  the  symptoms  are  largely  objective,  the  operator 
discovering  the  conditions  through  instrumentation,  and  the 
noxious  gases  encountered. 

Treatment  of  Open  Putrescence.  Excavate  the  cavity  to 
complete  exposure  of  the  pulp  chamber.  Flood  with  a  stream 
of  water  from  the  syringe.  Apply  the  rubber  dam  and 
sterilize  all  teeth  and  surfaces  exposed.  For  this  purpose  use 
a   ten  per  cent   solution   of   formaldehyd  to   which   has   been 


MANAGEMENT  OF  PUTRESCENT  ROOT  CANALS  119 

added  a  small  amount  of  borax.  Another  efficient  sterilizing 
agent  is  bichloride  of  mercury,  1-500  in  cinnamon  water. 
Mechanically  remove  the  contents  of  the  pulp  chamber  and 
flood  the  open  cavity  with  hydrogen  dioxide,  repeating  the 
dioxogen  two  or  three  times  or  until  active  effervescence 
ceases.  Apply  absolute  alcohol  and  evaporate  to  complete 
dryness.  AA^ith  an  extra  fine  barbed  broach  mechanically 
clean  each  root  canal  with  hydrogen  dioxide.  Care  should  be 
taken  not  to  force  any  of  the  putrescent  matter  through  the 
foramen,  removing  the  contents  of  the  canal,  portion  by  por- 
tion. The  canals  should  then  be  dried  with  alcohol  evapora- 
tion. Follow  this  with  a  fifty  per  cent  solution  of  sulphuric 
acid,  allow  this  to  remain  three  or  four  minutes  when  it 
should  be  thoroughly  diluted  with  water  and  the  canals  dried. 
Apply  campho-phenique  and  desiccate  to  dryness.  For  the 
final  dressing  flood  with  phenol,  pumping  to  the  apex  of  each 
canal  with  a  smooth  broach.     To  this  add  the  following  paste  : 

Iodoform. 

Phenol  Q.  S.  to  make  a  paste  sufficiently  stiff 
to  be  handled  to  the  cavity  on  a  large  spoon  excavator.  If 
crystallization  takes  place  add  a  drop  of  water.  Avoid 
glycerine  or  alcohol.  By  a  pumping  motion  of  the  broach 
the  paste  will  be  thinned  and  follow  the  phenol  already  in 
the  canal  to  the  apex. 

By  alternately  adding  the  paste  and  absorbing  the  excess 
phenol  the  canal  can  be  filled  with  a  comparatively  thick 
paste.  Fill  the  pulp  chamber  with  a  pellet  of  dry  cotton. 
Hermetically  seal  the  cavity  with  temporary  stopping  or 
cement,  preferably  for  a  week  or  ten  days,  when  the  case  will 
almost  invariably  return  ready  for  permanent  root  filling.  If 
a  shred  of  vital  pulp  is  encountered  in  the  apical  third  it  will 
have  been  devitalized  by  the  phenol  and  that  without  pain  or 
noticeable  soreness. 

The  Chief  Objection  to  This  Form  of  Treatment  is  the 
obnoxious  odor  of  the  iodoform.  The  deodorized  prepara- 
tions, however,  will  not  accomplish  the  desired  results.  Care 
should  be  taken  that  the  iodoform  is  kept  moist  at  all  times 


120  ESSENTIALS  OF  OPERATIVE  DENTISTRY 

and  finally  deposited  in  the  fountain  spittoon.  Each  teacher 
has  a  different  treatment  for  putrescence  and  the  student  is 
advised  to  familiarize  himself  with  all.  However  the  above 
is  a  one  sitting,  successful  treatment  and  its  trial  is  advised 
particularly  where  other  methods  have  resulted  in  pain  to 
the  patient  and  oft  repeated  visits  to  the  dental  chair. 

In  Cases  of  Long  Standing  Putrescence,  which  are  gener- 
ally open  cases,  the  dentine  is  thoroughly  saturated  with 
poisonous  ptomaines,  amido  acids  and  end  products.  These 
must  be  gotten  rid  of  and  the  most  expedient  method  is  to 
chemically  change  these  irritating  gases  and  poisonous  liquids 
into  non-irritating  and  nonpoisoning  liquids  and  solids. 
This  is  most  successfully  done  through  the  use  of  for- 
maldehyd.  Formaldehyd,  however,  is  very  irritating  to  vital 
tissues  and  should  not  be  brought  into  contact  with  them. 
Therefore  its  use  is  contra-indicated  in  cases  of  large  apical 
foramen.  Also  not  indicated  in  cases  where  a  portion  of  the 
vital  pulp  remains,  as  many  times  intense  pain  will  be  in- 
duced. To  modify  the  irritating  effects  there  may  be  added 
of  a  ten  per  cent  solution  of  formaldehyd  an  equal  bulk  of 
either  phenol,  creosote  or  creosol,  the  latter  being  preferable. 
This  should  be  sealed  in  the  cavity  and  crown  ends  of  the 
canals  for  twenty-four  or  forty-eight  hours  before  thorough 
broaching  of  the  canals  is  attempted.  Following  the  removal 
of  the  above  treatment  the  canals  should  receive  a  bath  first 
of  water  and  then  of  alcohol  to  carry  away  in  solution  the 
compounds  resulting  from  the  chemical  action  of  the  for- 
maldehyd. 

Animal  Fats,  which  consist  of  carbon,  hydrogen  and 
oxygen,  are  liable  to  be  present  in  abundance  in  recent  cases 
of  putrescence  and  should  be  removed  from  the  dentinal  walls 
as  they  readily  undergo  fermentative  decomposition. 

Their   Removal   Is    Best   Accomplished   by   soaponification 

through  the  action  of  sodium  dioxide.  This  should  be  ap- 
plied at  the  time  of  broaching  the  canals,  using  a  plantinum 
broach.  Following  its  use  the  canals  should  receive  a  water 
bath. 


:MANAGEMEXT  of  putrescent  root  canals  121 

Symptoms  of  Closed  Putrescence,  (class  two.)  Closed 
putrescence  without  complications  is  usually  of  short  dura- 
tion and  when  they  are  presented  for  treatment  before  com- 
plication there  generally  remains  a  portion  of  the  pulp  in  the 
apical  region  yet  vital. 

The  chief  pathogomonic  symptom  is  that  heat  produces 
paroxysms  of  pain  while  cold  applications  bring  relief. 

The  Treatment  for  Closed  Putrescence  is  to  apply  the 
rubber  dam  and  with  a  small  drill  open  directly  to  the  pulp 
chamber  when  temporary  relief  will  be  immediate.  The 
opening  should  then  be  enlarged  and  the  necrotic  pulp  tissue 
removed.  If  no  vital  pulp  tissue  is  found  the  case  should  be 
proceded  with  as  before  outlined  for  cases  of  open  putres- 
cence. ^^'hen  a  vital  portion  of  the  pulp  remains  nothing 
will  be  more  palliative  than  the  phenol  and  iodoform  paste 
treatment  already  outlined.  This  paste  will  also  devitalize 
the  remaining  portion  of  the  pulp.  Pressure  anesthesia  is 
certainly  not  indicated  in  such  cases  from  the  liability  of  in- 
fecting the  pericementum.  Neither  is  an  arsenical  applica- 
tion permissible  within  a  root  canal,  hence  the  phenol  treat- 
ment is  best  practice. 

Autogenous  Putrescence  of  the  pulp,  (class  three)  is  oc- 
casionally met  with  and  may  be  of  long  standing  without  com- 
plications of  the  apical  tissues  and  only  discovered  when  the 
dentine  of  the  crown  is  found  to  be  devital.  Such  cases  are 
generally  of  traumatic  origin  primarily,  the  putrescent  con- 
dition developing  long  after  the  death  of  the  pulp  by  the 
egress  through  the  apical  foramen  of  facultative  anaerobic 
"bacteria.  Such  cases  are  dealt  with,  when  treated,  as  any 
case  of  closed  putrescence,  excepting  that  extra  precaution 
as  to  access  must  be  taken  as  the  admittance  of  the  air  to 
such  cases  seems  to  render  the  putrescent  matter  most  virul- 
ent and  the  dangers  of  complications  are  most  extreme. 
Cases  presented,  of  recent  origin,  which  may  be  classed  as 
autogenous  are  generally  complicated  when  they  come  to  the 
dentist  as  the  complication  is  the  cause  of  the  patient's  visit, 
when  they  would  be  classed  as  a  case  of  closed  putrescence. 


122  ESSENTIALS  OF  OPERATIVE  DENTISTRY 

Their  cause  is  the  entrance  of  infection  through  the  circula- 
tion, the  bacteria  having  been  picked  up  in  pus  areas  not  far 
distant  from  the  apical  foramen.  Strictly  speaking  there  are 
no  autogenous  diseases  or  conditions,  such  as  auto-infection 
as  all  in  this  life  is  the  result  of  extrinsic  causes  more  or  less 
remote  from  the  body  but  the  classification  of  autogenous 
putrescence  of  the  pulp  is  given,  based  upon  the  same  theories 
and  principles  as  those  applied  in  general  pathology,  wherein 
the  immediate  cause  is  not  at  all  apparent. 

The  Symptoms  of  Complicated  Putrescence  (fourth  class) 
vary  from  slight  soreness  to  percussion  to  the  symptoms  ac- 
companying most  violent  and  acute  inflammatory  processes 
even  with  general  febrile  disturbances.  Other  cases  will  pre- 
sent themselves  with  an  entire  absence  of  all  the  above  sym- 
ptoms, the  only  evidence  of  pericemental  complications  be- 
ing detected  by  observation  or  instrumentation.  It  is  gen- 
erally true  that  the  acute  cases  show  the  more  marked  symp- 
toms, and  the  extremes  of  easy  and  difficult  management  are 
encountered,  whereas  with  chronic  complications  the  symp- 
toms are  not  so  marked  and  generally  yield  to  stereotyped 
methods  of  treatment  except  where  great  destruction  of  tissue 
has  taken  place,  where  such  cases  should  come  under  the 
head  of  surgery. 

The  Treatment  in  Complicated  Putrescence  is  as  varied 
as  the  symptoms  presented  and  the  conditons  found.  The 
first  order  of  procedure  is  the  removal  of  the  cause  which  in- 
cludes the  elimination  of  the  putrescent  conditions  within  the 
root  canal  under  aseptic  precautions.  If  the  pericementum 
is  only  inflamed  and  the  presence  of  pus  is  not  probable, 
the  treatment  is  the  same  as  that  outlined  for  uncomplicated 
putrescence,  adding  external  applications  to  the  gum  over  the 
affected  tooth  to  stimulate  resolution.  Painting  with  aconite 
and  iodine  is  suggested. 

In  Acute  Complication  where  pus  has  formed  and  upon 
broaching  is  freely  evacuated  down  the  root  canal,  it  is  the 
best  of  surgery  to  allow  free  drainage  by  this  route  for  twenty- 
four  or  forty-eight  hours  before  attempting  further  treatment. 
At  the  end  of  this  time  the  most  active  symptoms  will  have 


MANAGEMENT  OP  PUTRESCENT  ROOT  CANALS  12S 

generally  subsided  and  the  case  can  be  proceeded  with.  How- 
ever, there  have  been  some  cases  so  deeply  affected  beyond 
the  apex  of  the  tooth  that  external  painting-  on  the  alveolar 
wall  is  probable  and  only  avoided  by  immediate  extraction  ot 
the  tooth.  In  such  cases  the  salvage  of  the  tooth  depends 
upon  the  ability  of  the  patient  to  withstand  the  pain  to  the 
termination.  They  may  be  assisted  in  this  through  the  gen- 
eral administration  of  sedatives.  Locally  the  application  of 
revulsives  to  the  gum  will  hasten  the  external  pointing.  Eva- 
cuation ushers  in  the  stage  of  convalescence  and  the  treatment 
of  the  root  canals  may  be  proceeded  with. 

In  Chronic  Complications  of  putrescence  where  the  drainage 
is  through  the  root  canal  only  the  case  may  answer  to  the 
treatment  of  the  root  canal.  However  other  cases  will  de- 
mand special  treatment  for  the  sterilization  of  the  enclosed 
pocket  beyond  the  foramen.  The  greatest  danger  in  the 
treatment  of  this  class  is  in  suddenly  converting  them  into 
acute  form.  This  can  generally  be  avoided  by  attempting  the 
treatment  of  the  sub-dental  conditions  only  followmg  com- 
plete and  absolute  sterilization  of  the  communicating  canal. 
That  there  is  a  communicating  canal  in  these  cases  of  so-called 
"blind  abscesses"  is  self  evident  and  this  opening  permits  of 
treatment  without  the  use  of  root  canal  drills,  a  method  which 
is  not  advised  and  a  practice  wholly  unwarranted  resulting, 
many  times,  in  rendering  the  case  beyond  the  possibilities  of 
cure. 

If  the  case  must  have  additional  drainage  it  is  a  case  of 
surgical  procedure  and  the  point  of  attack  should  be  through 
the  external  alveolar  wall,  a  method  sometimes  resorted  to 
with  good  results. 

Alveolar  Abscess  With  Chronic  Fistula,  generally  with  the 
opening  on  the  external  alveolar  wall,  is  a  complication  re- 
sulting from  a  closed  case  of  putrescence  of  long  standing 
and  when  not  associated  with  necrosis  or  denuded  root  is  not, 
as  a  rule,  hard  to  manage. 

The  Treatment  of  chronic  alveolar  abscess  is  to  thoroughly 
sterilize  the  root  canal,  then   the   fistulous  tract.     The  tract 


124  ESSENTIALS  OF  OPERATIVE  DENTISTRY 

should  be  established  by  forcing  hamamelis  or  cassia  water 
through  the  root  canal  and  out  the  fistula.  Follow  this  with 
phenol  or  acomte  and  iodine  only  sufficient  to  cauterize  the 
entire  surface  of  the  tract  thus  destroying  the  fibrous  lining, 
improperly  called  the  "pyogenic  membrane."  Then  proceed  as 
with  any  other  case  of  putrescence,  filling  the  root  canal  before 
closure  of  the  fistula  has  been  effected.  Some  advise  the  entire 
treatment  and  root  filling  at  the  first  sitting,  but  it  is  probable 
that  better  results  will  be  obtained  if  case  is  allowed  a  week  or 
ten  days  between  the  first  treatment  and  the  root  filling  for 
complete  sterilization  of  the  dentinal  walls. 


FILLING  OP  ROOT  CANALS  12.^ 


CHAPTER  XX 

The  Filling  of  Root  Canals. 

It  is  Necessary  to  Fill  Root  Canals  Following  the  removal 
of  the  pulp,  to  prevent  the  exit  of  bacteria  or  other  products 
to  the  tissues  beyond  the  foramen,  and  to  prevent  the  dissolu- 
tion of  the  encompassing  walls  of  dentine. 

A  Root  Canal  is  Ready  for,  and  should  receive  the  root  fill- 
ing when  the  canal  is  void  of  all  else  than  air  and  it  is  not 
desired  to  again  reach  the  pericemental  tissues  for  treatment. 
To  render  a  canal  void  of  all  else  than  air  is  by  no  means 
universally  easy,  yet  it  is  the  object  sought  and  the  conditions 
are  not  ideal  until  this  result  is  obtained.  This  involves  the 
removal  of  all  pulp  tissue,  moisture,  bacteria  and  their  pro- 
ducts as  well  as  all  medicines  and  chemicals  used  in  the  pro- 
cess of  treatment. 

The  Perfect  Root  Filling  is  one  which  permanently  occupies 
the  entire  space  of  the  root  canal  and  closes  the  apical  foramen 
to  the  exit  or  entrance  of  all  substances,  particularly  gases 
and  fluids. 

The  Requirements  of  a  Material  for  Filling  a  root  canal  are 
that  it  be  non-soluble  in  the  fluids  of  the  body.  That  it  be 
non-irritating  to  soft  tissues.  Permanent  as  to  bulk  and  con- 
sistency. Not  subject  to  putrefaction  or  chemical  changes. 
Capable  of  easy  introduction,  and  it  is  an  additional  virtue  if 
the  material  used  can  be  again  removed  from  the  canal  after 
months  or  even  years  of  occupancy. 

The  Objective  Point  in  root  canal  filling  is  in  the  region  of 
the  foramen.  This  point  must  be  reached,  made  surgically 
and  therapeutically  clean,  completely  vacated  and  then  per- 
manently sealed  with  a  suitable  material. 

Small  Root  Canals  and  particularly  if  they  are  tortuous,  are 


126  ESSENTIALS  OF  OPERATIVE  DENTISTRY 

a  hindrance  to  always  attaining  ideal  results  and  even,  in  rare 
cases,  thwart  effort  to  save  teeth  thus  afflicted. 

The  Means  of  Cleansing  and  Vacating  small  and  tortuous 
root  canals  are  both  mechanical  and  chemical. 

It  is  Best  Accomplished  mechanically  by  the  use  of  small, 
flexible,  blunt  pointed  twisted  reamers,  which  enlarge  the 
canal  to  the  extent  of  entrance  by  cutting  away  the  sides  to 
increase  their  caliber  until  broaches  of  other  forms  will  be  ad* 
mitted.  This  process  is  assisted  chemically  by  flooding  the 
canal  with  a  fifty  percent  solution  of  sulphuric  acid,  as  this 
will  dissolve  and  soften  the  dentinal  walls,  thus  facilitating 
the  enlargement  of  the  canals. 

In  Cases  Where  the  Root  is  Bent  on  its  Long  Axis  it  is  es- 
sential that  the  broach  should  be  rounded  and  blunt  of  point 
that  it  may  follow  the  canal  and  not  cut  its  side  wall  at  the 
bend  of  the  canal,  which  will  produce  a  shoulder  and  hinder 
further  progress.  This  is  essential  with  the  finest  of  broaches 
and  requires  preparation  on  the  part  of  the  dentist  of  every 
broach  used  in  this  class  of  work,  as  all  broaches  that  come 
from  the  factory  have  a  very  sharp  point  entirely  unfitting 
them  for  opening  bent  root  canals.  This  blunting  process  is 
best  accomplished  by  holding  the  end  of  the  broach  at  an 
obtuse  angle  on  the  face  of  a  fine  cuttle  fish  disk  while  re- 
volving in  a  dental  engine,  at  the  same  time  twisting  the 
broach  from  right  to  left. 

The  carrying  of  cotton  into  a  root  canal  is  of  assistance  in 
the  drying  process  and  requires  the  special  preparation  of  a 
broach  to  facilitate  the  application. 

The  Cotton  Carrying  Broach  is  prepared  by  taking  a  per- 
fectly smooth  fine  hook  broach  and  by  grasping  with  a  pair 
of  flat  nosed  pliers  say  the  sixty-fourth  part  of  an  inch  from 
the  end,  rock  the  pliers  back  and  forth  until  the  end  is  broken 
off.  This  results  in  a  blunt  broken  surface  on  the  end  which 
engages  the  fibres  of  the  cotton-twist  and  prevents  same 
from  slipping  up  the  broach  towards  the  handle,  as  you  intro- 
duce it  into  the  canal,  allowing  the  cotton  to  be  carried  to  the 
depth  that  the  caliber  of  the  canal  will  permit. 


FILLING  OF  ROOT  CANALS  127 

The  Cotton  is  Applied  to  the  broach  by  taking  a  few  fibres 
between  the  thumb  and  first  finger,  place  around  the  broach, 
twist  the  handle  of  the  broach  to  the  right  at  the  same  time 
moving  the  thumb  and  finger  to  roll  the  broach  in  the  same 
direction. 

If  it  is  intended  to  leave  the  cotton  in  the  canal  as  a  dressing 
roll  upon  the  broach  tightly  at  the  point  only,  and  when  intro- 
duced to  the  entire  depth  of  the  canal  twist  broach  to  the  left 
part  of  a  turn  and  use  a  tamping  motion  and  cotton  will  be 
disengaged  and  packed  in  the  canal.  If  it  is  intended  to  re- 
move the  cotton  with  the  broach,  roll  tightly  its  entire  length 
and  when  cotton  is  being  introduced,  as  well  as  during  with- 
drawal, twist  broach  to  the  right  continuously  as  this  will 
cause  the  broach  to  maintain  a  tight  hold  on  the  cotton. 
When  all  has  been  removed  grasp  the  cotton  between  the 
fingers,  twist  broach  to  the  left  and  cotton  is  easily  disen- 
gaged. 

The  most  Popular  Root  Filling  of  today  is  gutta-percha,  a 
portion  of  which  is  dissolved  in  chloroform  to  facilitate  its 
introduction.  However  the  less  amount  of  chloroform  or  any 
other  fluid  there  is  in  the  finally  completed  filling,  the  better, 
as  these  constituents  are  not  permanent. 

Methods  of  Use.  The  canal  must  be  entirely  vacant  ex- 
cept the  air  which  it  contains  for  its  entire  length,  not  forget- 
ting that  this  includes  the  removal  of  all  moisture  possible. 

The  First  Step  is  to  Replace  this  air  with  a  fluid  that  is  a 
solvent  of  rubber.  A  very  popular  substance  for  this  pur- 
pose is  the  oil  of  Eucalyptol  as  this,  in  addition  to  being  a 
solvent  for  gutta-percha,  is  sHghtly  antiseptic  and,  being  an 
oil,  does  not  mix  with  any  blood  serum  or  moisture  that  has, 
perchance  escaped  the  operator's  notice  in  tht  apical  end  of 
the  canal,  or  may  have  a  tendency  by  capillary  attraction  to 
exude  into  the  mouth  of  the  foramen,  floating  the  same  from 
the  walls. 

The  Introduction  of  Chlora-Percha  is  accomplished  by  dip- 
ping a  small  broach  into  the  container  and  carrying  the  broach 
thus  loaded,  to  each  canal.     Carry  same  to  the  foramen  and 


128  ESSENTIALS  OF  OPERATIVE  DENTISTRY 

by  a  pumping  motion  the  chlora-percha  is  mixed  with  the 
Eucalyptol,  and  no  air  or  moisture  will  be  imprisoned  within 
the  canal. 

The  Introduction  of  the  Gutta-Percha  Canal  Point  is  here 

accomplished  by  grasping  the  large  end,  which  may  be  flat- 
ened  with  the  cotton  pliers  or  attaching  same  to  the  warmed 
end  of  a  root  canal  plugger,  withdraw  the  smooth  broach  which 
has  been  allowed  to  remain  part  way  up  the  canal  and  immedi- 
ately enter  the  small  end  of  the  canal  point  and  shove  entirely 
to  place  by  a  steady  gentle  pressure. 

The  Size  of  the  Canal  Point  should  be  great  enough  to  fill 
the  canal  entirely  full.  It  should  be  about  a  millimeter  longer 
to  permit  of  slight  tamping  at  the  mouth  of  the  canal.  The 
size  may  have  been  previously  ascertained  by  measurement 
and  trial,  which  is  good  practice  for  a  beginner.  An  experi- 
enced operator  will,  in  most  instances,  be  able  to  judge  as  to 
size  without  measurement. 

Slight  Flinching  on  the  part  of  the  patient  or  the  sense  of 
of  fullness  is  quite  a  trustworthy  guide  as  to  having  reached 
the  apical  end  of  canal  in  recent  cases  of  devitalization,  but 
such  symptoms  should  not  be  sought  in  devital  teeth  of  long 
standing,  particularly  if  there  has  been  a  loss  of  any  of  the 
tissue  in  the  apical  space.  However  in  these  cases  as  with 
all  others,  care  should  be  taken  that  perfect  and  complete  fill- 
ing of  the  apical  foramen  has  been  accomplished,  which  is 
ideal.  Yet  to  fill  slightly  beyond  the  canal  by  a  fraction  of  a 
niillimeter  is  a  less  error  than  to  not  entirely  fill  the  canal. 
The  opening  of  the  root  canal  should  now  be  tamped  solid, 
which  process  is  aided  by  warming  the  protruding  end  of  the 
canal  point. 

Cleanse  Pulp  Chamber  of  all  traces  of  gutta-percha  and 
case  is  ready  for  final  operation. 

The  practice  of  filling  pulp  chambers  with  rubber  in  any 
form  is  condemned  as  it  is  in  no  way  suitable  for  the  seat  of 
a  filling.     Cement,  amalgam  or  tin  is  preferable. 


EXTRACTION  OF  PERMANENT  TEETH         12^ 


CHAPTER  XXI 

Extraction   of  Permanent   Teeth. 

General  Consideration.  Under  normal  conditions  tooth 
extraction  is  not  a  difficult  operation.  However,  there  is  no 
oral  surgeon  even  of  experience  who  meets  with  universal 
success.  There  are  abnormal  conditions  which  render  un- 
successful any  attempts  at  removal  by  ordinary  means ;  but 
if  the  patient  is  placed  under  an  anesthetic  there  are  instru- 
ments manufactured  and  competent  and  able  surgeons  to 
handle  them,  that  can  remove  the  tooth  entirely,  and  if  need 
be  the  entire  maxillae  with  it.  Yet  there  is  a  limit  to  all 
operations. 

There  is  a  time  to  stop.  All  oral  surgeons  have  had  the 
same  experience,  finding  cases  where  the  unavoidable  injury 
to  the  tissues  in  removing  the  tooth  would  do  more  harm 
than  allowing  a  small  part  of  the  tooth  to  remain.  To  the 
laity  however  the  skilful  extraction  of  a  tooth  seems  "quite 
a  trick."  For  instance,  the  blacksmith  or  a  man  of  great 
strength,  who  has  not  made  a  careful  study  of  the  teeth  and 
their  environment,  may  attempt  to  extract  the  tooth  and  fail. 
One  who  has  made  the  subject  a  study,  although  possessed 
of  far  less  strength,  removes  the  same  tooth  skilfully,  and 
seemingly  without  the  exertion  of  much  muscular  effort. 
Unless  the  force  is  properly  and  scientifically*  applied,  it  ac- 
complishes nothing,  but  injury.  If  the  force  is  applied  in  a 
proper  direction,  with  proper  movements,  the  dislocation  of  a 
tooth  is  quite  an  easy  matter.  The  old  saving  that  there  is 
no  rule  without  an  exception,  and  that  the  exception  proves 
the  rule,  will  apply  to  the  rules  for  extraction :  for  there  is 
probably  as  much  difference  in  the  formation  of  teeth  and 
adjacent  structure  as  in  the  facial  expression  of  different  per- 
sons.    Therefore  it  is  difficult  to  formulate  any  rules  which 


130  ESSENTIALS  OP  OPERATIVE  DENTISTRY 

we  can  follow  literally  in  all  cases.  Still  the  extraction  of 
teeth  is  best  accomplished  by  the  application  of  scientific 
principles. 

These  principles  properly  applied  will  give  better  results 
than  extracting  the  teeth  merely  to  get  them  out.  For  this 
reason  we  must  study  that  which  we  wish  to  accomplish 
and  how  best  to  accomplish  it,  by  considering  the  various 
shapes  of  that  part  of  the  teeth  which  cause  their  retention 
in  the  jaw;  also  the  structures,  strength  and  position  of  those 
tissues  which  hold  the  teeth  in  place. 

Principal  Retention.  The  constricted  portion  of  a  tooth 
at  its  neck  serves  to  retain  the  tooth  firmly  in  the  alveolar 
process,  and  constitutes  its  principal  retention,  by  the  process 
grasping  the  tooth  at  this  point,  assisted  by  natural  adhesion 
of  the  tissues. 

Opening  Mouth  of  Alveolus.  The  alveolar  process  is  just 
a  little  thicker  or  heavier  at  the  neck  of  the  tooth  than  just 
below.  The  gingival  part  of  the  alveolus,  the  tooth's  socket, 
is  called  the  mouth  of  the  alveolus.  This  mouth  once  opened, 
which  can  be  accomplished  by  slight  fracture  at  this  point, 
the  remo\'al  of  a  normal  tooth  is  made  easy. 

How  can  this  best  be  accomplished?  By  application  of  force 
upon  the  line  of  least  resistance.  This  varies  in  different  teeth, 
owing  to  the  difference  in  anatomical  structure,  the  number  of 
roots  and  direction  of  eruption. 

Three  forces  are  applied  in  the  extraction  of  a  tooth:  Trac- 
tion, Rotation  and  Pressure. 

Traction  is  a  pulling  force ;  rotation  is  a  motion,  given  the 
hand  in  using  a  screw  driver,  but  moving  the  hand  first  in 
one  direction  then  in  another.  Pressure  is  the  force  we 
would  apply  to  a  tooth  in  endeavoring  to  push  it  in  or  out 
of  the  mouth  at  an  angle  to  its  long  axis. 

Position  and  Movements.  If  the  patient  is  of  mature  years 
and  as  is  often  the  case  possessed  of  as  much  or  more  strength 
than  the  dental  surgeon,  it  is  very  essential  that  we  consider 
position  and  movements  and  that  we  have  so  calculated  these 
matters  that  the  patient  is  at  all  times  fully  under  the  control 
of  the  operator.     It  is  not  well  to  give  the  patient  to  under- 


EXTRACTION  OF  PERMANENT  TEETH         131 

Stand  that  we  think  this  particular  tooth  is  a  very  difficult 
one  to  extract,  or  that  we  are  in  the  least  timid  about  per- 
forming the  operation. 

Securing  Patient's  Confidence.  After  it  has  been  decided 
to  extract  the  tooth,  the  more  precise  and  deliberate  the  opera- 
tor's actions,  the  more  confidence  the  patient  will  have,  hence 
a  firm  but  gentle  hand  instills-  into  the  patient's  mind  con- 
dence  in  the  operator's  ability.  In  giving  the  positions  of 
the  patient  and  operator,  it  is  assumed  that  the  latter  is  right 
handed.  If  such  is  not  the  case,  the  positions  would  be  re- 
versed. 

Position  of  Patient's  Head,  The  patient's  head  should  be 
inclined  backward.  It  should  be  firmly  fixed  and  absolutely 
under  the  control  of  the  operator.  This  can  be  accomplished 
in  different  ways  in  the  absence  of  a  dental  chair  with  its 
head  rest  and  other  conveniences,  in  which  case  the  operator 
may  be  compelled  to  resort  to  very  primitive  means. 

With  All  Superior  Teeth  the  operator  should  stand  back 
of  the  patient  and  a  little  to  the  right,  placing  the  crown  of 
the  head  against  the  chest  of  the  operator,  putting  the  left 
hand  around  to  the  left  of  patient's  head  with  the  index  finger 
holding  the  lip  away  from  the  alveolar  process  and  at  the 
same  time  lying  against  the  process,  to  detect  at  once  any 
extensive  injury  which  might  result  from  a  fracture.  The 
middle  or  second  finger  should  be  placed  back  of  the  forceps 
when  the  tooth  is  on  the  left  side;  or  against  the  palatine 
process  when  the  tooth  is  on  the  right  side.  Then  by  press- 
ing the  patient's  head  firmly  against  the  head  rest,  or  against 
the  operator's  chest,  if  using  a  low  chair  or  stool  it  is  entirely 
from  under  the  control  of  the  patient,  when  inclined  in  a 
backward  position. 

The  Position  in  Extracting  the  Lower  Teeth  is  nearly  the 
same,  except  that  the  relative  position  of  patient  should  be 
lower.  The  general  position  for  all  inferior  bicuspids  and 
molars  is  the  same  as  for  the  superior.  In  extracting  inferior 
incisors  and  cuspids  stand  directly  behind  the  patient,  and 
use  a  straight  or  bayonet  shaped   forceps,  such  as  are  used 


132  ESSENTIALS  OP  OPERATIVE  DENTISTRY 

in  the  extraction  of  superior  incisors.  The  patient's  head 
should  be  the  height  of  the  operator's  waist  Hne,  he  standing 
directly  back  of  patient. 

Position  of  Hands.  The  index  finger  should  press  down 
the  lower  lip  and  inspect  the  alveolar  process.  The  thumb 
should  be  placed  on  the  lingual  surface  of  the  process  and  the 
three  remaining  fingers  should  grasp  the  chin  firmly,  that  the 
lower    jaw  may  be  fully  under  control. 

Operating  at  Arm's  Length.  In  no  case  leave  your  patient 
or  step  in  front  of  him,  using  the  hand  and  your  forceps  at 
arm's  length  for  with  the  head  at  liberty,  a  sudden  twitch  or 
jerk  on  the  part  of  the  patient,  would  either  destroy  or  mis- 
guide the  force  applied  and  either  thwart  the  effort  to  remove 
the  tooth  or  perhaps,  by  increasing  the  pressure  in  the  wrong 
direction  cause  permanent  injury.  Just  as  an  operator  is  ex- 
tracting the  tooth,  he  is  often  troubled  by  the  patient  grasping 
the  arm  which  is  using  the  forceps.  This  is  a  serious  matter, 
especially  when  extracting  a  lower  tooth,  as  the  line  of  force, 
which  the  operator  wishes  to  exert  is  opposite  to  that  in  which 
the  patient  can  exert  great  force  thus  resulting  in  diminishing 
the  power  of  the  former. 

Overcoming  Resistance  of  Patient.  At  this  point  the 
operator  is  justified  in  a  sharp  reprimand,  even  bordering 
upon  crossness,  perhaps  getting  the  patient  to  desist  for  a 
moment,  when  the  operation  may  be  completed.  The  only 
precaution  for  guarding  against  such  a  turn  of  affairs  is 
perhaps  a  suggestion  that  the  patient  hold  the  hands  of  a 
friend  or  grasp  the  arm  or  seat  of  the  chair,  instructing  him 
to  give  a  vigorous  pull  just  as  you  start  to  extract  the  tooth. 
This  may  assist  him  to  endure  the  pain  which  is  sometimes 
unavoidable  when  local  or  general  anesthetics  are  contra-in- 
dicated. 

Superior,  Central  and  Lateral  Incisors.  Traction  or  force 
applied  parallel  to  its  long  axis.  Next  rotation.  Why?  Be- 
cause this  is  a  single  rooted  tooth  and  the  root  is  slightly 
rounded. 


EXTRACTION  OF  PERMANENT  TEETH         133 

Also,  should  any  of  the  adhering  portions  of  the  alveolar 
process  be  in  danger  of  removal,  the  rotary  motion  will  loosen 
that  portion  from  the  tooth. 

For  example,  if  upon  the  removal  of  a  nail  from  a  board, 
part  of  the  board  should  adhere,  the  twisting  of  the  nail 
would  remove  from  it  the  adhering  wood  by  bringing  it  in 
contact  with  the  greater  body  of  the  board.  Next  comes 
pressure,  outward,  or  labial,  because  this  is  in  the  line  of 
least  resistance  as  the  process  is  much  thinner  on  the  labial 
than  on  the  lingual  aspect. 

Do  not  alternate  the  motion  between  labial  and  lingual 
pressure,  as  any  pressure  lingually  accomplishes  nothing  but 
increased  pain,  for  before  the  tooth  can  be  removed  the 
mouth  of  the  alveolus  must  be  opened  and  this  can  only  be 
effected  by  labial  pressure. 

All  change  of  force  should  be  of  a  rotary  nature,  with  a 
slight  labial  pressure,  and  sufficient  traction  to  remove  the 
tooth  upon  the  slightest  fracture,  or  giving  of  the  process  at 
the  mouth  of  the  alveolus. 

Inferior,  Central,  and  Lateral  Incisors.  Traction  in  a  line 
parallel  with  the  long  axis  of  the  tooth.  Rotation  none  be- 
cause these  teeth  have  flat  roots  with  their  greatest  trans- 
verse diameter,  labio-lingual.  Any  twisting  or  attempts  at 
rotating  these  four  teeth  will  only  endanger  their  slender 
roots.  Pressure  slightly  labial,  because  this  is  in  the  line  of 
least  resistance,  the  process  being  thinner  on  the  labial  aspect. 

Superior  Cuspids  Traction, — A  considerable  amount  of 
force  is  required  to  remove  this  tooth,  as  it  is  the  longest 
tooth  in  the  human  mouth.  It  is  generally  most  firmly  seated 
and  as  a  rule  requires  more  force  for  its  removal  than  any 
other.  Slight  rotation,  especially  when  the  first  bicuspid 
and  lateral  incisor  are  in  position.  The  root  of  this  tooth 
is  not  quite  so  nearly  round  as  that  of  the  central  incisors;  but 
rotation  should  be  applied  to  prevent  a  fracture  of  the  adher- 
ing process  of  the  lateral  surface.  This  rotation  tends  to  peel 
or  scale  off  any  adhering  process  by  bringing  it  in  contact 
with  the  firmer  portion  not  disturbed. 


134  ESSENTIALS  OF  OPERATIVE  DENTISTRY 

Pressure  must  be  steadily  labial,  as  this  is  in  the  line  of 
the  least  resistance.  By  "steadily  outward,"  we  do  not  mean 
to  grasp  the  tooth,  and  draw  it  out  at  right  angles  with  the 
long  axis  of  the  tooth ;  but  that  in  addition  to  the  great 
amount  of  traction  necessary  and  the  slight  rotation  there 
should  be  a  certain  amount  of  labial  pressure  upon  the  process. 

There  is  one  case  where  this  rule  for  the  extraction  of  the 
superior  cuspid  may  be  ignored.  When  the  first  biscuspid 
and  lateral  incisor  has  just  been  extracted.  In  this  case 
instead  of  grasping  the  cuspid  labio-lingually,  place  the  beaks 
of  the  forceps  a  short  distance  up  into  the  cavities  of  the 
freshly  extracted  teeth,  thus  grasping  the  tooth  mesio-distally 
and  give  the  tooth  great  traction ;  also  rotation  in  one  direc- 
tion. 

This  rotation  should  be  so  applied  that  the  labial  ^lortion 
of  the  cuspid  would  be  moved  towards  the  median  line.  The 
reason  the  motion  should  be  applied  only  in  this  direction  can 
be  found  in  the  fact  that  frequently  the  roots  of  cuspid  teeth 
turn  or  bend  backward,  as  they  advance  up  in  the  process. 
Using  traction  and  rotation  in  this  one  direction  the  principle 
is  applied  which  removes  a  corkscrew  from  a  cork. 

Inferior  Cuspids.  Traction :  Slight  Rotation :  Labial 
pressure.  The  rules  for  the  extraction  of  inferior  cuspids  are 
quite  similar  to  those  for  the  superior  cuspids,  adding  only 
that  owing  to  the  curve  sometimes  found  in  its  single  root, 
it  is  well  to  direct  the  line  of  traction  force  a  little  backward. 

Superior  Bi-Cuspids.  Principally  Traction :  Parallel  with 
the  long  axis  of  the  tooth.  Owing  to  the  small  size  of  the 
root  in  both  cases  and  the  first  biscuspid  frequently  having 
a  double  root,  other  forces  must  be  sparingly  used  in  the 
removal  of  this  tooth.  Minute  rotation,  could  only  be  used 
in  second  bicuspid,  this  being  a  single  rooted  tooth.  The  first 
bicuspid  is  generally  possessed  of  two  roots.  When  not 
sufificiently  bifurcated  to  be  classed  as  two  distinct  roots,  they 
are  so  united  as  to  form  a  very  flat  root  with  the  greatest 
diameter  bucco-lingually. 


EXTRACTION  OF     PER.AIAXENT  TEETH  135 

Pressure,  which  is  outward  as  this  is  in  the  line  of  least 
resistance  owing  to  the  thinness  of  process  on  buccal  aspect, 
must  be  sparingly  used ;  not  so  much  because  you  would 
endanger  the  process  by  great  force  in  this  direction,  for  it 
is  considerably  thicker  over  the  bicuspid  than  over  the  cuspid 
roots ;  but  because  there  is  danger  of  breaking  the  root  just 
below  the  mouth  of  the  alveolus,  or  close  to  where  the  roots 
begin  their  bifurcation.  With  the  second  superior  bicuspid 
the  pressure  outward  may  be  greater,  bearing  in  mind  that 
the  roots  of  these  teeth  are  disproportionally  long  compared 
with  their  circumference  at  the  neck. 

Inferior  Bicuspids.  Principally  Traction.  In  applying 
this  force  bear  in  mind  that  the  line  of  the  greatest  length  of 
these  teeth  is  normally  inclined  backward  instead  of  being 
in  all  cases  at  a  right  angle  to  the  plane  of  occlusion.  There- 
fore, the  traction  must  be  applied  in  a  direction  which  would 
move  the  tooth,  if  it  suddenly  came  loose,  towards  the  first 
molar  or  back  of  where  it  normally  occludes. 

Minute  Rotation,  for  the  reason  that  these  are  also  slender 
rooted  teeth  and  quite  frequently  somewhat  curved.  As  a 
rule  these  teeth  are  possessed  of  but  one  root.  The  pressure 
should  be  minutely  buccal,  for  this  is  in  the  line  of  least  resis- 
tance. Care  should  be  taken  not  to  injure  the  upper  teeth 
when  inferior  bicuspids  and  first  molars  leave  their  sockets 
suddenly,  as  they  sometimes  do.  Injury  to  the  other  teeth 
through  striking  them  with  the  forceps  is  more  likely  to 
occur  in  extracting  bicuspids,  as  the  force  of  traction  should 
be  applied  in  a  direction  which  would  bring  them  in  contact 
with  the  upper  teeth. 

Superior  First  and  Second  Molars.  These  teeth  are 
grouped  together,  as  in  the  case  of  the  bicuspids,  on  account 
of  similarity  in  form,  position  and  parts  surrounding  them. 
Traction  should  be  applied  in  the  direction  of  a  line  drawn 
from  the  central  pit  of  this  tooth  to  the  apex  of  the  lingual 
root.  Rotation  none.  y\ny  motion  in  the  way  of  rotation 
would  not  loosen  the  tooth,  as  one  root  would  brace  the  other. 
It  is  therefore  advantageous  to  apply  the  force  in  the  line  of 
the  greatest  length  of  one  of  these  roots:     viz.,  the  lingual. 


136  ESSENTIALS  OP  OPERATIVE  DENTISTRY 

Pressure  should  be  applied  steadily  buccally  and  not  re- 
leased until  the  mouth  of  the  alveolus  is  opened.  The  pro- 
cess over  the  lingual  root,  which  is  the  palatine  process  of  the 
superior  maxillae,  is  quite  thick  and  heavy  and  seldom  gives 
to  any  extent,  but  the  two  buccal  roots,  are  no  great  distance 
from  the  soft  tissues  and  by  this  steady  buccal  pressure  this 
process  gives  and  the  tooth  is  allowed  exit.  Care  should 
be  taken  not  to  make  this  pressure  too  strong  or  apply  it  too 
suddenly,  as  the  two  roots  in  such  close  proximity  may  act  as 
a  lever  and  loosen  a  considerable  portion 'of  the  buccal  plate. 

Inferior.  First  and  Second  Molars.  Traction,  the  force  of 
which  should  be  applied  not  only  upward  but  backward,  re- 
membering that  the  apices  of  the  two  roots  are  not  d^^ectly 
under  the  crown  but  posterior  to  it,  giving  the  root  a  curve 
backward. 

A  Common  Error  is  made  when  the  force  of  traction  is 
applied  at  a  right  angle  to  the  plane  of  occlusion.  Rotation 
none.  For  as  these  are  double  rooted  teeth  rotation  accom- 
plishes nothing  except  to  increase  the  pain  by  alternately 
increasing  and  releasing  the  pressure  upon  the  highly  vascu- 
lar and  sensitive  peridental  membrane.  Pressure  should  be 
directly  buccal.  Although  it  may  seem  to  the  operator  that 
the  process  is  thinner  upon  the  lingual  aspect  of  the  inferior 
maxillae,  this  is  generally  not  the  case.  Yet,  as  with  all 
lower  teeth,  a  mal-occlusion  or  an  irregularity  may  make  the 
process  thicker  on  the  buccal  surface. 

Superior  Third  Molars.  Traction.  Rotation  in  but  one  di- 
rection, one  that  would  roll  the  top  of  the  hand  towards  the 
median  line.  Pressure  should  be  buccal  and  at  the  same 
time  distal.  Being  the  last  tooth  in  the  mouth  and  seated  at 
the  angle  of  the  jaw,  it  is  not  very  firmly  supported  by  the 
process,  which  in  some  cases  is  almost  entirely  wanting  on 
the  posterior  buccal  corner. 

Inferior  Third  Molars.  Traction  should  not  be  only  up- 
ward, but  backward,  which  can  be  accomplished  after  grasp- 
ing the  tooth  with  the  beaks  of  the  forceps,  and  allowing  the 
handle  to  lie  across  and  near  the  anterior,  inferior  teeth.     As 


EXTRACTION  OF     PERIMANENT  TEETH  137 

the  traction  is  applied  raise  the  handles  and  you  have  an 
amount  of  spring  which  will  tilt  the  crown  backwards  in 
proportion  to  the  distance  the  anterior  teeth  are  separated 
by  the  opening  of  the  mouth.  Here  we  have  the  only  tooth 
in  which  there  is  almost  a  universal  exception  to  the  direction 
in  which  the  pressure  should  be  applied  to  be  in  the  line  of 
the  least  resistance.  In  the  case  of  the  third  inferior  molar, 
it  is  to  the  lingual.  The  coronoid  process  of  the  inferior 
maxillae  comes  down  ending  in  the  external  oblique  line  which 
is  an  eminence  and  materially  thickens  the  jaw  bone  just 
buccal  to  the  third  molars. 

It  must  also  be  remembered  that  there  is  little  of  the  alve- 
olar  process  formed  around  the  third  molar,  seldom  more  than 
that  portion  which  builds  in  around  the  neck  to  insure  its 
retention.  Therefore  when  the  tooth  is  broken  off  it  at  once 
becomes  a  very  difficult  task  to  remove  the  remaining  portion, 
owing  to  the  strength  and  width  of  the  bone  at  this  point. 

Care  should  be  taken  not  to  employ  great  pressure  lingually 
as  the  anatomical  structure  at  this  point  favors  fracture 
which  most  frequently  extends  down  and  back  to  include  the 
inferior  dental  foramen  connected  with  the  hylo-hyoid  groove. 

Injury  in  this  way  at  this  particular  point  may  be  far- 
reaching  in  its  effect,  as  fractures  are  most  likely  to  follow 
weakened  portions  of  the  bone,  and  in  this  case  they  overlie 
the  inferior  dental  nerve  and  vessels. 

As  to  the  pain  attending  tooth  extraction  it  may  be  mater- 
ially lessened  and  many  times  entirely  relieved  by  injecting 
into  the  tissues  to  be  lacerated  some  good  local  anaesthetic 
The  following  has  proved  to  be  good  and  is  one  the  author 
recommended  to  the  profession  in  1902. 

Cocaine  Tablets  l-6th  grain.  Parke  Davis  and  Company's 
No.  150  was  especially  prepared  for  this  combination. 

Adrenalin  Chloride  1  gtt. 

Ext.  Witch  Hazel  Q.S.  25  M. 

Sig.  Inject  close  to  tooth.  If  possible  insert  needle  be- 
tween cementum  and  alveolar  process.  In  pyorrhea  cases  in- 
ject in  body  of  the  gum  margin. 


138  ESSENTIALS  OF  OPERATIVE  DENTISTRY 

When  pus  is  Present.  It  is  understood  that  any  injection 
is  contra-indicated  when  pus  has  formed  in  or  near  the  tissues 
to  be  injected. 

Hemorrhage  Following  Extraction.  Excessive  Hemor- 
rhage frequently  follows  tooth  extraction,  and  is  more  fre- 
quently met  with  in  cases  after  extracting  first  or  second  lower 
molars. 

In  Mild  Cases  a  tampon  of  cotton  saturated  with  hydrogen- 
dioxid  or  adrenalin  chloride  crowded  well  to  the  bottom  of 
the  alveolus  from  which  the  hemorrhage  is  coming  will 
usually  be  sufificient. 

In  Severe  Cases  a  tampon  made  of  the  scrapings  of  oak 
tanned  sole  leather  will  prove  effective.  The  scrapings  are 
made  by  the  dentist  from  a  pieece  of  sole  leather  by  scraping 
shreds  from  the  edge.  These  should  be  previously  prepared 
and  ready  for  an  emergency.  They  should  be  placed  in  a 
large  mouthed  bottle  and  sterilized  by  dry  heat  and  securely 
corked. 

Method  of  Applying.  When  case  presents,  there  should 
be  three  pellets  made,  small,  medium  and  large  about  the  size 
of  the  alveolus.  These  should  be  introduced  quickly  one  after 
the  other  and  pressed  to  position  and  held  there  for  some 
minutes  with  the  ball  of  the  finger. 

The  leather  scrapings  will  swell  and  effectually  plug  the 
alveolus.  Also  the  tannin  in  the  leather  liberates  the  fibrino- 
gen and  an  impervious  clot  is  formed.  Within  24  hours  the 
last  applied  pellet  of  scrapings  will  have  been  raised  out  of 
the  socket  and  the  next  two  will  soon  follow. 

This  is  recommended  as  a  method  that  has  never  failed  in 
a  long  list  of  desperate  cases  but  should  not  be  resorted  to 
except  as  an  extreme  measure  as  great  soreness  frequently 
follows  the  treatment  due  to  the  interference  with  the  circula- 
tion for  some  considerable  distance  about  the  bleeding  alve- 
olus. 

Surgical  Means.  With  cases  of  hemorrhage  from  lower 
teeth  the  ligation  of  the  inferior  dental  artery  just  posterior 


EXTRACTION  OF  PERMANENT  TEETH         139 

to  its  entrance  to  the  inferior  dental  canal  may  be  resorted 
to  and  will  prove  effectual. 

Why  this  means  is  not  more  frequently  resorted  to  by  gen- 
eral practitioners  is  a  question  as  the  operation  is  not  a  diffi- 
cult one. 

Technic  of  Ligation.  A  three  inch  straight  needle  is  passed 
through  the  integument  just  below  and  posterior  to  the  angle 
of  the  mandible.  The  needle  should  carry  a  heavy  braided 
silk  thread.  The  needle  is  made  to  hug  the  mandible  on  the 
inner  side  till  it  merges  within  the  mouth,  and  thread  drawn 
part  way  through.  The  needle  is  again  started  back  some 
distance  from  the  mandible  and  made  to  emerge  through  the 
external  opening  in  the  skin. 

A  knot  is  then  tied  in  this  with  sufficient  force  to  compress 
the  inferior  dental  artery  which  will  be  found  to  have  been 
engaged  within  this  loop.  After  a  few  hours  this  can  be 
loosened  to  test  for  hemorrhage  and  finally  entirely  withdrawn 
when  all  danger  has  ceased  leaving  practically  no  scar  upon  the 
external  tissues. 

Hypodermic  Injections  of  Adrenalin  Chloride  for  hemor- 
rhage following  extraction  is  good  practice.  Load  the  syringe 
part  full  of  hamamelis  to  which  has  been  added  5  drops  of 
adrenalin  chloride.  Introduce  the  needle,  which  should  be 
long  and  large,  into  the  apical  space  and  inject  a  few  drops. 
Repeat  two  or  three  times  if  necessary. 

Capillary  Hemorrhage.  If  the  hemorrhage  is  capillary,  in- 
ject into  the  tissues  from  which  the  blood  is  coming. 


140 


ESSENTIALS  OF  OPERATIVE  DENTISTRY 


CHAPTER  XXII 

Extraction  of  Temporary  Teeth. 

The  extraction  of  temporary  teeth  at  the  proper  time 
and  under  normal  conditions  is  not  a  difficult  operation,  ow- 
ing to  the  amount  of  physiological  resorption  of  both  alveolar 
process  and  roots  of  the  teeth. 

The  Most  Important  Thing  Connected  With  Their  Extrac- 
tion is  an  accurate  knowledge  of  the  order  in  which  nature 
proposes  to  replace  them  with  the  permanent  set. 
.  Results  From  a  Disregard  of  This  Order.  The  premature 
or  tardy  extraction  of  temporary  teeth  has  more  to  do  with 
irregular  and  unsightly  permanent  teeth  than  any  other  one 
cause.  Therefore  it  is  well  to  make  a  careful  study  of  the 
order  in  which  the  temporary  set  is  replaced. 


3-3-6-4 -5 


i-z-i'—i—s 


First 

Permanent 

Molar 


Figure  18.  Represents  the  complete  set  of  deciduous  teeth,  witii 
the  first  permanent  molar  added.  Lower  row  of  figures  represent 
the  order  the  deciduous  teeth  generally  erupt.  Upper  row  of  figures 
represent  the  order  of  their  replacement  by  the  permanent  set. 


EXTRACTION  OF  TEMPORARY  TEETH         141 

Time  of  Eruption  of  the  First  Permanent  Molar.  The  first 
molar  teeth  make  their  appearance  at  between  five  and  six 
years  of  age. 

They  are  generally  supposed  by  the  laity  to  be  deciduous 
and  are  frequently  allowed  to  decay  beyond  remedy  before 
the  mistake  is  discovered.  They  are  then  extracted  without 
much  thought,  either  through  necessity  or  from  being  mis- 
taken for  temporary  teeth  by  the  physician  on  account  of  the 
youth  of  the  patient.  The  parents  are  wonderfully  surprised 
to  find  such  enormous  roots  on  what  they  beheve  to  be  a 
temporary  tooth. 

Duty  of  Dentist  in  This  Matter.  The  practitioner  of  den- 
tistry has  a  very  important  duty  to  perform  in  insisting  upon 
the  retention  of  this  tooth ;  for  through  its  loss  a  decided 
derangement  of  the  permanent  set  results  and  lack  of  proper 
development  of  the  jaw  is  encouraged. 

First  Permanent  Tooth  to  Erupt.  Figure  18  is  a  side  view 
of  child's  jaw  at  about  the  sixth  year.  No.  1  top  row  is  the 
first  molar,  and  is  a  part  of  the  permanent  set,  the  second 
and  third  molars  coming  in  after  the  temporary  set  has  been 
entirely  replaced  by  permanent  teeth. 

Reasons  for  a  Permanent  Tooth  at  This  Time.  Nature  in 
giving  us  this  permanent  tooth  at  this  particular  time  and  lo- 
cated at  this  particular  place,  seems  to  desire  to  put  in  a  per- 
manent fixture  as  a  dividing  line  in  the  jaw  between  the  teeth 
which  are  to  be  replaced,  and  those  which  are  not,  as  shown 
by  line  A. 

Evil  Effects  of  Early  Extraction.  If  By  Proper  Extraction 
and  Coaching  Into  Place  of  the  \arious  tcclh  in  their  proper 
order  the  position. of  this  line  A,  which  bisects  the  jaw  just 
at  the  mesial  of  the  first  permanent  molar,  is  not  allowed  to 
move  anteriorly,  there  is  left  just  the  proper  space  which  the 
permanent  teeth  will  occupy  when  they  replace  the  tempo- 
rary set,  provided  the  jaw  development  is  not  interfered  with, 
but  if  by  the  premature  extraction  of  the  second  tenii)orary 
molar,  this  first  permanent  molar  is  allowed  to  tip  forward, 
thereby  moving  line  A  anterior!}-,  we  have  encroached  just 
that  much   upon   the  space  reqnircTl  by   the  permanent   teeth. 


142 


ESSENTIALS  OF  OPERATIVE  DENTISTRY 


The  irregularity  resulting  from  such  a  mistake  will  probably 
be  shown  in  the  cuspid  as  this  is  the  last  of  the  temporary 


Figure  19.     Irregularity    resulting   from    premature    extraction    of 
first  deciduous  molar. 


set  to  be  replaced.  (See  figure  19.)  Again,  if  the  first  per- 
manent molar  is  extracted  before  the  temporary  teeth  have 
been  replaced,  nature  seems  to  realize  that  further  development 
of  the  jaw  on  this  side  is  not  necessary,  and  the  jaw — be  it 
lower  or  upper — will  generally  lack  in  length  to  correspond 
with  its  antagonist,  the  width  of  the  tooth  extracted.  This 
may  not  be  noticed  in  the  exhibition  of  faulty  occlusion  or 
irregularities  but  a  careful  study  of  the  features  will  show 
lack  of  artistic  contour. 

Let  us  here  consider  the  order  in  which  the  temporary  teeth 
are  replaced  by  the  permanent  set.  By  reference  to  figure 
eighteen,  you  will  see  that  the  order  differs  somewhat. 

The  lower  figures  represent  the  order  of  eruption  of  the 
temporary  set.  The  upper  figures  represent  the  order  of  the 
replacement  by  the  permanent  set  including  this  first  perma- 
ment  molar.  Nature  has  wise  reasons  for  this  change  in  the 
order. 

The  Inferior  Teeth  Generally  Precede  the  Superior  in  the 
anterior  part  of  the  mouth  by  a  few  weeks  and  in  the  posterior 
part  by  a  few  months  with  the  exception  of  third  molars. 
The  inferior  third  molars  sometimes  precede  the  superiors 
by  years.     It  must  also  be  borne  in  mind  that  the  variance  in 


EXTRACTION  OF  TEMPORARY  TEETH  143 

length  of  time  and  age  of  eruption  is  shorter  in  the  case  of 
females  than  of  males. 

Difference  in  Time  as  to  Sex.  Some  females  erupt  their 
third  molars  as  young  as  the  sixteenth  year,  some  males  do 
not  erupt  them  as  late  as  the  twenty-seventh  year.  They 
may  be  in  part  or  entirely  wanting  in  either  male  or  female 
during  life.  They  are  sometimes  so  far  retarded  that  they 
do  not  erupt  until  after  the  extraction  of  the  first  and  second 
molars  late  in  life.  Thus  giving  rise  to  an  idea  in  the 
patient's  mind  that  he  has  at  least  part  of  a  third  set  of  teeth. 

Compare  Orders  of  Eruption.  A  careful  consideration  of 
the  two  tables  will  show  that  in  the  temporary  set  the  cuspid 
teeth  erupt  before  the  temporary  molars,  while  these  are  re- 
placed by  the  permanent  teeth  in  a  different  order.  The  first 
temporary  molar  is  replaced  by  the  first  bicuspid.  Then  the 
second  temporary  molar  is  replaced  by  the  second  bicuspid 
and  next  we  have  the  cuspid  tooth  coming  into  place,  form- 
ing the  keystone  of  the  arch. 

The  Reason  for  Nature's  Change  of  This  Order.  At  five 
years  we  find  the  full  complement  of  temporary  teeth  in  place, 
only  twenty  in  number.  Then  nature  puts  in  this  dividing 
line  by  putting  into  place  one  permanent  tooth,  the  first  per- 
manent molar,  before  she  makes  any  attempt  at  interfering 
with  the  temporary  arch  already  established. 

When  this  tooth  is  fully  in  place  nature  begins  her  work 
of  replacement.  First  come  the  centrals,  then  the  laterals, 
and  if  we  were  to  follow  the  order  in  which  these  same  tem- 
porary teeth  were  erupted  we  would  next  have  the  cuspid, 
but  not  so,  we  have  the  first  temporary  molar  lost  and  re- 
placed by  the  first  bicuspid,  and  as  this  temporary  molar  is 
lost,  the  first  bicuspid  has  a  space  to  occupy  between  two 
teeth,  which  .should  be  in  position  to  guide  and  assist  it  to 
proper  place,  leaving  the  second  temporary  molar  in  position 
to  hold  the  first  permanent  molar  in  its  correct  position. 
Then  nature  replaces  the  second  temporary  molar  with  the 
second  bicuspid.  Note  that  these  two  temporary  molars  are 
wider  than   the   permanent   bicuspids  taking  their   place,   but 


lU  ESSENTIALS  OF  OPERATIVE  DENTISTRY 

the  cuspid  of  the  permanent  set  is  wider  than  the  temporary 
cuspid. 

Loss  of  Temporary  Cuspid.  As  soon  as  the  temporary 
molars  have  been  replaced  by  the  bicuspids,  the  temporary 
cuspids  should  be  lost  and  replaced  by  the  permanent  cuspids, 
which  as  stated  before,  forms  the  keystone  of  the  arch,  and 
being  a  little  wider  wedges  the  two  bicuspids  quickly  back 
into  position  against  the  first  permanent  molar.  Coming  in- 
to position  just  in  this  order  and  at  this  time  it  is  easily  seen 
how  the  first  permanent  molar  is  kept  in  its  proper  place.  At 
this  time  the  question  may  arise  as  to  how  the  permanent 
centrals  and  laterals  find  sufficient  room,  being  so  much 
larger  than  their  predecessors.  This  is  compensated  for  by 
the  development  of  the  maxillae  at  this  age.  Some  authors 
advance  the  idea  that  the  difference  in  the  space  occupied  by 
these  four  teeth  was  compensated  for  by  the  permanent  bi- 
cuspids being  smaller  than  the  temporary  molars. 

We  can  not  agree  with  this :  For  when  the  four  incisor 
teeth  are  erupted  in  position  in  almost  every  instance  the 
temporary  cuspid  retains  its  former  and  original  place. 

Having  completed  the  changing  of  the  temporary  teeth 
nature  will  add  teeth  to  the  posterior  part  of  the  jaw  without 
any  danger  of  subsequent  irregularities. 

Evils  Resulting  From  Disregarding  the  Order  in  Which 
the  Temporary  Teeth  are  Replaced  by  the  Permanent,  in  their 
extraction.  For  instance,  if  ,  as  we  are  frequently  requested 
by  our  patrons,  we  extract  lateral  incisors  before  the  central 
incisors  have  attained  nearly  their  proper  height  in  the  pro- 
cess of  eruption,  either  one  of  the  two  evils  may  result. 

The  central  incisors  in  the  inferior  maxilla  stand  on  either 
side  of  the  symphysis,  or  where  the  two  segments  of  the  jaw 
bone  unite.  In  the  superior  maxilla  the  central  incisors  stand 
on  either  side  of  the  median  line  in  the  intermaxillary  bones. 
If  the  temporary  laterals  are  extracted  before  the  centrals 
are  fully  erupted,  should  the  jaw  continue  proper  develop- 
ment, the  central  incisors  will  stand  apart  as  they  do  not 
ha\'e  the  lateral  incisors  to  hold  them  toward  the  median 
line.     Thus  when   the   laterals   attempt   to  come   into   place. 


EXTRACTION  OF  TEMPORARY  TEETH         145 

their  space  has  been  encroached  upon  and  they  may  fail  to 
crowd  the  centrals  over  to  place. 

However  in  most  cases  the  bones  do  not  continue  proper 
development  and  the  space  between  the  two  temporary 
cuspids  occupied  by  the  four  temporary  incisors,  is  not  suf- 
ficiently increased  to  accommodate  the  permanent  incisors ; 
hence  the  crowded  condition  frequently  met  with. 

Therefore  extract  no  lateral  incisors  until  the  central  in- 
cisors are  quite  in  position.  If  the  central  incisors  do  not 
seem  to  have  sufficient  room,  instruct  the  patient  to  put  pres- 
sure with  the  tongue  or  fingers  in  the  labial  direction  which 
will  put  them  into  proper  position ;  but  for  no  reason  whatever 
extract  the  laterals  before  the  centrals  have  attained  their 
proper  height  in  the  line  of  occlusion. 

Xext  we  lose  the  lateral  incisors.  As  this  tooth 
erupts  after  the  temporary  lateral  has  been  extracted,  it  very 
frequently  loosens  the  temporary  cuspid,  which  by  this  time 
has  had  its  root  quite  freeh^  resorbed.  Patients  then  request 
that  the  cuspid  be  extracted  as  the  lateral  has  not  sufficient 
room.  A'ery  frequently  it  will  look  as  though  this  was  neces- 
sary. However  if  we  extract  the  cuspid  at  this  point  rest 
assured  that  there  will  not  be  room  enough  for  the  perma- 
nent cuspid,  when  it  wishes  admittance  to  the  arch.  We 
should  insist  upon  the  retention  of  the  cuspids  and  as  the 
lateral  crowds  for  room,  development  all  through  the  jaw 
and  especially  at  the  median  line  will  take  place. 

In  the  superior  jaw  the  intermaxillary  bones  materially  de- 
velop at  this  age,  and  as  the  temporary  cuspid  is  not  lost  un- 
til between  the  eleventh  and  thirteenth  year  the  development 
is  ample.  So  the  incisor  teeth  (the  two  centrals  and  two 
laterals),  have  allotted  to  them  the  space  between  the  tempo- 
rary cuspids,  as  well  as  that  which  is  made  by  the  growth 
of  the  jaw  between  the  time  of  their  eruption  and  the  loss  of 
the  cuspid  teeth. 

Therefore  the  lateral,  which  did  not  seem  to  have  space 
enough  when  it  erupted  will  have  ample  space  in  five  years 
as  it  is  that  long  before  any  teeth  in  its  immediate  vicinity 
are  disturbed.     Nature  then  skii)s  this  cuspid  tooth  which  is 

(5) 


,  146  ESSENTIALS  OF  OPERATIVE  DENTISTRY 

to  hold  the  incisors  in  place,  and  the  first  temporary  molar 
is  replaced  by  the  bicuspid  which  has  ample  room  and  needs 
'  little  attention  beyond  the  removal  of  its  predecessor  at  the 
proper  time.  Just  at  this  point  the  second  temporary  molar 
may  become  decayed  or  lost  and  patients  will  insist  upon 
its  extraction ;  but  if  by  any  means  the  patient  can  be  made 
comparatively  comfortable  it  should  not  be  extracted  as  its 
removal  allows  the  first  permanent  molar  to  move  forward 
caused  by  the  growing  and  developing  second  permanent 
molar  at  this  age.  When  the  first  bicuspid  is  fully  erupted 
.  to  the  line  of  mastication,  you  are  justified  in  removing  the 
second  temporary  molar  to  give  place  to  its  successor.  Dur- 
ing the  eruption  of  the  first  bicuspid,  the  cuspid  will  very  fre- 
quently become  loose  and  possibly  hard  to  retain,  and  the 
patient  will  again  insist  upon  its  removal ;  but  do  not  extract 
at  this  time. 

Leave  the  temporary  cuspid  in  position  until  all  of  the 
other  teeth  have  been  replaced.  If  the  order  which  nature 
has  mapped  out  has  been  preserved,  an  even  set  of  teeth  will 
result  in  almost  every  instance.  'If  the  order  has  been  inter- 
fered with  in  the  least,  the  patient's  mouth  is  placed  in  a  con- 
dition where  gross  irregularities,  faulty  occlusion  and  great 
disfigurement  is  almost  sure  to  result.  Therefore,  the  great 
necessity  for  the  preservation  of  nature's  order,  in  the  ex- 
traction of  the  temporary  teeth.  It  is  the  one  thing  to  be 
looked  after  and  adhered  to  and  should  be  disregarded  only 
in  extreme  cases,  which  does  not  mean  merely  the  satisfac- 
tion of  the  ideas  of  parents.  The  operation  of  extracting 
temporary  teeth  is  simple.  If  you  have  carefully  looked  the 
mouth  over  and  decided  that  it  is  necessary  to  extract  any 
tooth,  it  can  be  accomplished  with  almost  any  pair  of  forceps. 
Great  care  should  be  taken  not  to  take  too  deep  a  grasp  upon 
the  tooth,  that  the  developing  permanent  tooth,  which  is  sup- 
posed to  be  close  to  its  temporary  predecessor  may  not  be 
injured  in  the  removal  of  the  temporary  tooth.  It  is  also 
advantageous  to  use  a  lance  separating  the  gum  from  the 
tooth  as  the  gum  at  or  near  the  neck  of  the  tooth  frequently 


MANAGEMENT  OF  CAVATIES— (Class  1)  147 

adheres  quite  strongly  to  the  cementum.     By  using  the  lance, 
laceration  of  the  parts  is  avoided. 

When  there  is  nothing  left  but  the  separated  or  decayed 
points  or  unabsorbed  portions  of  roots,  it  is  best  to  remove 
them  with  a  root  elevator  or  chisel. 


CHAPTER  XXIII 
Management  of  Pit  and  Fissure  Cavities.     Class  1 

Location.  Class  one  cavities  occur  in  the  occlusal  surfaces 
of  molars  and  bicuspids ;  in  the  middle  and  occlusal  thirds  of 
the  buccal  and  lingual  surfaces  of  molars  and  in  the  lingual 
surfaces  of  incisors,  more  frequently  in  the  laterals. 

The  Predisposing  Cause  of  decay  in  these  localities  is  a 
fault  in  the  enamel  due  to  imperfect  closure  of  the  enamel 
plates,  affording  a  convenient  point  for  the  lodgment  of  food 
particles  and  the  active  principles  of  fermentation  which  is 
the  exciting  cause  of  all  tooth  decay. 

Extension  for  Prevention  is  Seldom  Necessary  in  this  class 
of  cavities  from  the  fact  that  the  surface  of  the  enamel  in  the 
immediate  neighborhood  is  exposed  to  the  friction  of  masti- 
cation. It  is  only  necessary  to  cut  away  the  enamel  walls 
sufficiently  to  uncover  the  area  of  affected  dentine  and  to 
include  in  the  cavity  outline  all  sharp  grooves  connected  with 
seat  of  primary  decay  to  a  location  that  will  permit  a  smooth 
finish  to  the  surface  of  the  filling  and  an  outline  devoid  of 
angles.  Figure  20  shows  simple  cavities  class  I  with  suf- 
ficient extension  when  there  is  supported  enamel. 


Figure  20. 

Tendency  to   Extensive   Dentinal   Decay   must  be  remem- 
bered   in    dealing   with    this    class    of   cavities   as   the    merest 


148  ESSENTIALS  OF  OPERATIVE  DENTISTRY 

Opening  through  the  enamel  will  frequently,  upon  excavation, 
show  an  extensive  loss  of  dentine. 

Incipient  Decays  in  Occlusal  Defects. 
Description.  Upon  examination  it  is  found  that  the  tine  of 
a  sharp  explorer  will  pass  between  the  non-united  plates  of 
enamel  to  the  depth  of  the  entire  thickness  of  enamel  in  one 
or  more  points.  A  more  careful  examination  may  show  the 
surface  of  the  dentine  to  be  softened  to  a  greater  or  less  ex- 
tent immediately  pulp-wise  from  the  enamel  fault.  Such 
cases  demand  immediate  attention.      (Figure  21.) 


Figure  21.     Showing  defective  pits  and  fissures  class  1. 

Outline  Form.  To  open  such  cavities  there  is  placed  in 
the  engine  a  discarded  No.  ^  or  1  round  bur  which  has  been 
made  into  a  spade  drill  by  flattening  on  two  sides.  This  drill 
is  made  to  travel  between  the  plates  of  the  enamel  through 
a  major  portion  of  the  defect,  which  results  in  widening  the 
fissure.  This  preliminary  step  will  result  in  much  saving  of 
burs,  as  a  bur  which  has  been  once  used  on  an  enamel  wall 
is  unfitted  to  cut  dentine.  The  common  practice  of  using 
dentate  fissure  burs  for  this  work  is  considered  as  brutal  to 
the  patient  and  is  a  thief  of  the  operator's  time.  A  No.  ^ 
or  1  (ound  bur  is  now  used  in  the  engine  and  applied  to  the 
den  nine.  By  swaying  the  hand  piece  to  and  fro  the  dentine 
is  cut  away  from  beneath  the  enamel  walls.  The  bur  should 
be  frequently  removed  to  allow  of  cooling  as  heat  readily 
develops  and  is  a  great  and  frequent  source  of  pain  to  the 
patient. 

The  Use  of  the  Chisel  is  next  advised  for  the  removal  of 
the  overhanging  enamel  wall ;  first  because  this  is  the  easiest 
and  speediest  means  of  its  accomplishment  and,  second,  be- 
cause this  is  the  only  means  of  securing  the  cleavage  of  the 


MANAGEMENT  OF  CAVATIES— (Class  1)  149 

enamel,  giving  the  operator  the  opportunity  to  judge  the 
amount  of  resistance  to  stress  in  the  several  locaHties,  and 
to  learn  of  the  direction  of  the  enamel  rods.  Many  times  a 
chisel-edged  hatchet  will  be  most  advantageous,  one  which 
has  a  chisel  edge  upon  the  sides  of  the  blade  as  well  as  the 
cutting  edge.  The  size  should  be  governed  by  the  size  of 
the  opening  secured,  but  in  every  case  use  as  large  an  instru- 
ment as  the  orifice  will  admit.  This  process  should  be  re- 
peated with  bur  for  cutting  dentine  and  chisel  or  hatchet  for 
cleaving  enamel  until  the  desired  cavity  outline  is  obtained. 
Resistance  Form.  Include  all  fissure  and  sulcate  grooves. 
Cross  all  grooves  and  ridges  at  as  near  a  right  angle  as  pos- 
sible. Avoid  eminences  of  primary  calcification.  Lay  the 
outline  as  much  as  possible  along  the  sloping  sides  of  the  tri- 
angles and  ridges,  as  these  are  the  most  favored  localities 
for  a  cavity  margin,  as  on  these  sloping  surfaces  we  find 
the  greatest  amount  of  friction  during  the  process  of  masti- 
caticn,  due  to  the  excursions  of  food,  and  they  are  the  least 
exposed  to  direct  stress,  as  the  blows  are  of  glancing  nature. 

Retention  Form.  A  good  rule  to  follow  in  cavities  of  class 
one  is,  when  the  depth  of  the  cavity  is  equal  to  or  greater 
than  the  width,  parallel  walls  are  sufficient.  But  when  the 
width  exceeds  the  depth  the  external  walls  should  meet  the 
internal  wall  at  a  slightly  acute  angle.  These  angles  are  best 
made  acute  by  the  use  of  a  chisel  edged  hatchet  or  hoe,  hav- 
ing corners  that  are  slightly  acute.  With  a  planing  motion 
they  should  be  made  to  travel  parallel  with  the  base  line 
angles.  This  will,  at  the  same  time,  flatten  the  seat  or  pulpal 
wall.  The  extreme  ends  of  long  arms  in  a  filling  such  as  re- 
sults from  following  a  slender  fissure  must  be  made  retentive. 

Convenience  Form.  No  convenience  form  is  usually  neces- 
sary in  small  cavities  class  one,  except  in  rare  instances  it 
may  be  of  advantage  to  sharpen  one  of  the  distant  point 
angle?  to  facilitate  the  starting  of  a  cohesive  gold  filling. 
But  usually  the  first  portion  of  gold  may  be  used  of  sufficient 
si;^e  to  entirely  cover  the  pulpal  wall  ,in  which  case  it  can  be 
securely   locked    to   position   between   the   surrounding  walls. 


150  BSSENTIALiS  OF  OPERATIVE  DENTISTRY 

Removal  of  Remaining  Decay.  By  this  time  the  carioujj 
dentine  will  usually  have  been  removed.  Should  any  remain 
it  should  be  excavated  with  suitable  spoons. 

At  this  point  there  should  be  a  thorough  inspection  of  the 
dento-enamel  junction  for  small  areas  of  softened  dentine 
which  may  have  escaped  notice. 

The  Walls  should  all  be  flat,  particularly  the  pulpal.  In 
cases  where  decay  has  progressed  so  deeply  into  the  dentine 
that  to  flatten  the  pulpal  wall  would  cause  the  involvment 
of  the  recessional  tracts  of  the  horns  of  the  pulp,  the  base 
line  angle  should  be  made  intermittent,  omitting  the  squar- 
ing of  the  angles  in  the  regions  of  the  recessional  tracts. 

Disinfection.  The  cavity  should  be  flooded  with  alcohol 
carrying  a  small  per  cent  of  formaldehyd,  say  one  or  one- 
half  per  cent,  and  evaporating  to  dryness. 

Finish  of  Enamel  Walls.  The  enamel  wall  should  be 
planed  for  the  entire  outline  of  the  cavity  with  a  sharp  chisel 
using  a  light  hand ;  the  desired  cavo-surface  angle  secured, 
and  the  bevel  angle  buried  to  the  desired  depth.  The  move- 
ment of  the  chisel  should  parallel  the  travel  of  the  external 
enamel  line. 

Toilet  of  the  Cavity.  The  cavity  should  be  swept  with  a 
tightly  rolled  cotton  ball  or  piece  of  spunk  in  the  pliers  and 
the  dust  finally  removed  with  a  blast  of  air  from  the  chip- 
blower,  and  the  filling  immediately  placed. 

Inlays.  If  the  cavity  is  to  be  occupied  by  an  inlay,  retent- 
ion form  may  have  been  omitted  and  applied  to  the  cavity 
just  before  setting  the  filling  in  which  case  the  toilet  of  the 
cavity  should  be  repeated.  If  the  cavity  has  already  been 
given  retention  form  the  same  should  be  temporarily  removed 
while  making  the  model  by  wiping  into  the  retaining  angles 
wax,  temporary  stopping,  or  cement  to  be  removed  before  final 
placing  of  the  filling. 


MANAGEMENT  OF  CAVATIES— (Class  1)  151 


CHAPTER  XXIV. 

Management  of  Pit  and  Fissure  Cavities.     Class  I  Concluded. 
Large  Cavities  in  Central  Fossa  of  Molars. 

Description.  Such  cavities  are  usually  the  result  of  know- 
ing neglect  on  the  part  of  the  patient.  However,  in  cases 
where  the  enamel  is  strong  and  of  a  good  resistant  quality 
or  the  teeth  are  so  occluded  as  to  have  received  little  stress 
the  patient  may  be  in  ignorance  of  the  great  havoc  which 
has  been  done,  due  to  the  major  portion  of  the  enamel  remain- 
ing intact.  There  may  exist  in  such  cases  only  the  slightest 
aperture  through  a  defective  fissure  or  fault  in  the  canal. 

Outline  Form.  This  division  of  class  one  should  be  opened 
with  a  straight  or  bin-angle  chisel  of  rather  large  size  to 
prevent  easy  passage  to  the  sensitive  pulpal  wall.  A  chisel 
of  from  two  to  three  millimeters  in  width  is  advised.  The 
securing  of  adequate  finger  rest  on  adjacent  tissues  is  im- 
portant. The  chisel  should  be  applied  so  as  to  throw  the 
chips  into  the  cavity  ,and  the  mallet  substituted  for  heavy 
hand  pressure.  It  is  best  to  begin  on  margins  most  mesial 
and  nearest  the  operator's  eyes,  as  this  increases  the  range 
of  vision  to  the  deeper  portions  of  the  cavity  at  an  early  stage 
in  the  procedure.  This  chipping  away  of  the  enamel  should 
be  continued  until  enamel  supported  by  sound  dentine  is 
reached  and  until  the  margins  have  been  carried  to  desired 
regions  as  set  forth  in  general  in  the  chapter  on  outline  form. 

When  Pulp  Exposure  is  Feared.  In  this  case  the  sixth 
step  in  cavity  jjrcparation  will  come  in  third  and  we  have  for 
consideration  the  removal  of  remaining  decay. 

Up  to  this  jjoint  only  the  most  superficial  examination  of 
the  internal  surfaces  has  been  made. 

Placing  the  Rubber  Dam  at  this  point  is  expedient  as  dry- 
ness  is  imperative.     The   decay   is   now   removed   with    large 


152  ESSENTIADS  OP  OPERATIVE  DENTISTRY 

spoon  excavators,  whose  blades  are  at  least  two  millimeters 
wide.  These  spoons  which  should  be  keen  of  edge  are  care- 
fully worked  under  the  edges  of  the  masses  of  softened  den- 
tine and  by  a  prying,  sweeping  movement  lifted  en  masse 
from  the  walls.  The  blade  of  the  excavator  should  be  pre- 
vented from  scraping,  or  sliding  over  the  regions  of  suspected 
exposure. 

When  the  Pulp  is  Exposed  or  nearly  so  the  operator  will 
proceed  to  pulp  treatment,  of  either  devitalization  or  conser- 
vation as  the  case  demands.  This  step  completed  outline 
form  is  again  taken  up  and  fissures  and  sulcate  grooves  in- 
cluded in  the  cavity  outline. 

Resistance  and  Retention  Forms.  As  to  resistance,  we 
have  only  to  consider  the  probable  stress  to  be  sustained  by 
the  filling  as  a  whole  and  of  the  margins  in  their  various 
localities.  This  will  involve  a  study  of  each  case  in  hand, 
as  to  occlusion  and  articulation  as  well  as  to  habits 
of  the  patient  in  mastication.  The  problem  of  concave 
pulpal  wall  is  here  met  in  its  most  exasperating  form. 
Many  times  if  the  operator  were  to  take  the  lower  levels  of 
the  pulpal  wall  and  attempt  to  flatten  and  carry  this  wall 
laterally  until  it  could  be  made  to  meet  surrounding  walls  at 
different  angles,  the  recessional  tracts  of  the  pulp  would  be 
crossed  and  exposure  of  that  organ  result. 

The  Flattening  of  the  Pulpal  Walls  Avoided.  This  lateral 
cutting  to  flatten  pulpal  walls  may  be  avoided  in  two  ways. 

First;  The  operator  may  establish  a  level  higher  up  on 
the  lateral  walls  for  the  creation  of  the  base  line  angles,  re- 
sulting in  steps.  These  steps  should  be  established  in  places 
most  remote  from  recessional  tracts,  which  will  generally  be 
found  to  be  in  the  neighborhood  of  developmental  grooves. 
There  should  be  at  least  three  of  the  steps  or  small  supple- 
mental seats.  Four  point  suspension  is  better.  As  the 
seats  are  small  and  will  probably  be  required  to  carry  rela- 
tively heavy  loads  their  angles  should  be  most  definite. 
,.  Second;  To  avoid  the  flattening  of  these  pulpal  walls  in 
large  cavities  of  this  class  build  the  metal  portion  of  the  fill- 
ing immediately  into  cement  which  has  been  applied  to  the 


MANAGEMENT  OF  CAVATIES— (Class  1)  153 

pulpal  wall.  This  renders  the  base  of  the  filling  adhesive  to 
its  seat  and  nullifies  the  tendency  of  the  filling  to  slip  or 
revolve  under  load. 

It  might  be  said  here  that  you  have  the  principle  of  the 
inlay  introduced  into  a  built-in  filling,  a  much  valued  feature 
by  many  operators. 

Convenience  Form.  There  is  no  convenience  form  required 
in  this  class  of  cavities  when  making  a  plastic  filling.  In  the 
making  of  a  cohesive  gold  filling  in  this  division  of  cavities 
care  must  be  taken  that  the  mesial  wall  can  be  reached  by 
direct  force  from  the  plugger  point.  In  some  cases  it  will 
be  required  to  move  the  mesial  margin  well  upon  the  mesial 
marginal  ridge,  to  accomplish  the  desired  result. 

Convenience  Point  for  the  beginning  of  the  first  pieces  of 
gold  should  be  obtained  through  the  use  of  a  small  quantity 
of  thin  cement  applied  to  the  deepest  portions  of  the  cavity. 

Finish  of  Enamel  Walls  and  Toilet.  The  cavity  should  be 
phenolized  and  the  same  evaporated  to  dryness.  The  entire 
cavity  outline  should  be  freshly  planed,  the  margins  slightly 
beveled  and  a  positively  determined  cavo-surface  angle  estab- 
lished. The  depth  the  bevel  angle  is  to  be  buried  should  be 
determined. 

The  cavity  should  be  thoroughly  swept  with  cotton,  the 
dust  dissipated  with  a  blast  from  the  chip  blower  and  the 
filling  immediately  placed. 

Pit  Cavities  in  Buccal  and  Lingual  Surfaces  of  Molars. 
These  cavities  have  their  origin  in  defects  in  the  enamel  on 
the  buccal  surface  of  lower  molars  and  the  lingual  surface  of 
upper  molars. 

Instrumentation  is  the  same  for  the  same  class  and  size  of 
ca\ities  just  described  on  the  occlusal  surface,  excepting  per- 
haps it  may  be  necessary  to  use  the  engine  burs  in  the  contra- 
angle  hand  piece,  a  necessity  seldom  met  with  on  the  occlusal 
surfaces. 

Outline  Form.  The  outline  should  be  carried  well  out  of 
the  pit  or  groove  and  sufficiently  extended  to  meet  the  gen- 
eral rules  given  in  the  cliaptcr  on  this  subjct. 


154  ESSENTIALS  OF  OPERATIVE  DENTISTRY 

Resistance  Form  will  come  up  for  consideration  only  when 
the  outline  approaches  the  occlusal  marginal  ridge.  In  such 
cases  if  the  occlusal  wall  is  not  made  up  of  a  sufficient  bulk  of 
dentine  to  withstand  the  stress  of  mastication  the  outline 
should  be  carried  over  the  marginal  ridge  to  the  occlusal  sur- 
face. In  which  case  the  rules  for  the  outline  of  this  portion 
of  the  cavity  will  be  the  same  as  previously  given  and  appli- 
cable to  all  cavities  invading  occlusal  surfaces. 

Extension  for  Prevention  will  come  in  for  consideration 
when  the  outline  has  for  other  causes  been  brought  near  to 
the  free  margin  of  the  gum.  A  full  application  of  the  rule 
"Extension  for  prevention"  would  demand  that  the  gingival 
outline  be  carried  under  the  free  margin  of  the  gum  when 
the  gum  has  already  been  approached  to  within  one  millimeter. 
A  failure  to  extend  the  outline  is  permissible  in  mouths  kept 
scrupulously  clean. 

Retention  Form.  This  step  is  very  simple  when  the  cavity 
does  not  involve  the  occlusal  surface  and  is  fully  obtained 
when  the  internal  line  angles  have  been  well  squared.  How- 
ever, when  the  cavity  reaches  the  occlusal  the  filling  is  sub- 
jected to  the  greatest  amount  of  tipping  strain  in  mastication. 
These  will  then  demand  a  flat  gingival  wall,  and  in  some  cases 
of  a  vital  tooth,  a  flat  pulpal  wall  placed  parallel  to  the  gin- 
gival wall,  and  the  line  angles  surrounding  these  walls  well 
defined.     The  four  point  angles  should  be  slightly  acute. 

Finish  of  Enamel  Walls.  In  the  management  of  these  axial 
surface  pit  and  fissure  cavities  the  varying  slant  of  the  enamel 
rods  should  not  be  lost  sight  of.  This  should  be  noted  when 
outlining  the  cavity  with  the  chisel.  The  rods  will  generally 
be  found  to  incline  towards  the  pit,  from  every  direction  close 
to  the  defect,  while  a  little  way  out  they  will  be  found  at 
right  angles  to  the  surface. 

Going  farther  toward  both  the  occlusal  and  gingival  the 
outer  ends  of  the  rods  will  be  found  to  incline  more  and  more 
away  from  the  seat  of  decay. 

These  facts  should  be  borne  in  mind  and  a  full  cleavage 
obtained. 


MANAGEMENT  OF  CAVATIES— (Class  1)  155 

There  now  remains  only  the  usual  marginal  bevel  and 
cavity  toilet. 

Pit  Cavities  in  Lingual  Surfaces  of  Upper  Incisors. 

Should  Receive  Early  Attention.  These  cavities  should  be 
detected  in  their  early  stages  as  their  near  location  to  the 
pulp  renders  pulp  complications  an  early  sequence. 

It  is  the  best  of  practice  to  permanently  fill  all  cases  pre- 
sented where  faults  in  enamel  are  diagnosed. 

Instrumentation.  Their  location  renders  excavation  haz- 
ardous. The  engine  bur  should  be  used  for  superficial  open- 
ing only,  the  most  of  the  preparation  being  done  with  hand 
instruments. 

Outline  Form.  The  general  rules  in  outline  form  should  be 
observed.  Particular  note  should  be  made  of  the  extreme 
incisal  inclination  of  the  outer  ends  of  the  enamel  rods  along 
the  margin  of  the  incisal  wall. 

Retention  and  Resistance  Form.  The  major  portion  of 
resistance  form  is  secured  by  leaving  a  flat  gingival  wall. 

Retention  Form  is  secured  by  relying  on  two  distinct  point 
angles,  namely,  the  gingio-axio-distal  and  the  gingio-axio- 
mesial. 

Inciso-Occlusal  Line  Angle.  It  is  generally  advisable  to 
allow  the  incisal  wall  to  meet  the  axial  at  quite  an  obtuse 
angle,  in  some  cases  almost  to  the  obliteration  of  this  line 
angle,  as  the  squaring  of  this  angle  will  greatly  endanger  the 
pulp. 


156  ESSENTIALS  OF  OPERATIVE  DENTISTRY 


CHAPTER  XXV. 

Management  of  Proximal  Cavities  in  Bi-Cuspids  and  Molars 

Class  Two. 

Location.  Class  two  cavities  are  those  which  originate  on 
the  proximal  surfaces  of  molars  and  bi-cuspids  at  a  point 
slightly  gingival  from  the  point  of  contact. 

Predisposing  Cause.  The  predisposing  cause  is  the  fact  of 
the  presence  of  the  adjoining  tooth  which  establishes  and 
maintains  the  sheltered  position  for  the  accumulation  of  sub- 
stances which  undergo  fermentative  decomposition. 

Early  Detection  of  These  Cavities  is  Essential.  It  is  of 
the  utmost  importance  that  class  two  cavities  be  discovered 
early.  More  pulps  are  lost  to  the  teeth  from  the  neglect  of 
these  cavities  than  from  any  other  cause.  Their  early  detec- 
tion is  by  no  means  an  easy  matter  to  the  inexperienced  oper- 
ator, as  many  times  their  presence  is  shown  only  by  a  change 
m  the  color  of  the  overlying  enamel. 

There  are  yet  other  cases  where  the  teeth  must  be  separated 
for  an  examination  of  the  suspected  surfaces. 

It  requires  education  in  the  use  of  the  explorer  to  detect 
the  difference  in  the  "feel"  of  the  explorer  tine  in  the  proximal 
space  and  the  entry  of  the  point  into  a  cavity  of  slight  depth. 
When  the  decay  has  extended  along  the  dento-enamel  junc- 
tion the  case  becomes  much  easier  and  should  never  escape 
the  detection  of  the  operator. 

Small  Proximal  Cavities,  Class  Two, 
Description.  By  examination  there  is  found  to  be  estab- 
lished an  area  of  decay  upon  the  enamel  surface  between 
contact  point  and  the  free  margin  of  the  gum,  on  one  or  both 
teeth  which  go  to  form  the  space  in  question.  The  dentine 
may  or  may  not  be  involved.  The  marginal  ridge  is  yet  in- 
tact and  firm.  The  enamel  shows  no  signs  of  injury  in  either 
the  buccal  or  lingual  embrasures. 


MANAGEMENT  OP  CAVITIES— (Class  2)  157 

Gaining  Access.  Opening  the  cavity  is  many  times  the 
most  difficult  step  in  the  procedure. 

There  are  three  plans  of  procedure  open  to  the  operator. 
The  one  most  common  and  oftentimes  the  best  is  to  place  the 
angle  of  a  sharp,  straight  chisel,  say  one  millimeter  in  width, 
on  the  proximal  slope  of  the  marginal  ridge  and  tap  it  lightly 
with  a  mallet ;  turn  the  other  angle  so  that  the  chisel  edge 
rests  at  forty-five  degrees  to  the  position  of  first  impact  and 
again  apply  the  mallet.  Repeat  this  several  times  and  this 
will  generally  break  away  the  enamel  rods  in  a  small  V 
shaped  space.  This  may  be  continued  vmtil  the  cavity  is 
completely  uncovered.  In  comparatively  resistant  cases  the 
bi-bevel  drill  may  be  applied  to  break  in  the  enamel. 

The  Second  Method  of  procedure  is  to  use  the  bi-bevel  drill 
in  the  mesial  or  distal  pit,  giving  the  hand  piece  that  slant 
which  will  cause  the  drill  to  enter  the  area  of  decay,  when 
sufficient  depth  has  been  reached.  The  chisel  is  then  applied 
and  the  occlusal  enamel  cleaved  away  either  by  hand  pres- 
sure or  the  mallet.  This  method  is  more  liable  to  cause  pain 
than  the  first  given  and  should  be  used  with  caution. 

The  Third  is  to  adjust  the  mechanical  separator  and  attack 
the  enamel  with  a  small  chisel  from  the  buccal  direction, 
gradually  shifting  more  and  more  to  the  occlusal  and  finally 
the  enamel  ridge  will  give  way  to  the  force  of  the  chisel. 

Preliminary  Separation  should  in  most  cases  be  resorted  to 
for  proper  access  for  the  many  reasons  set  forth  in  Chapter 
Six. 

This  is  Best  Accomplished  by  packing  the  cavity  at  this 
stage  with  gutta-percha  for  a  few  days  or  weeks.  When  case 
returns  we  should  be  ready  to  consider  outline  form. 

Outline  Form.  Outline  form  in  class  two  involves  the 
outlining  of  the  cavity  proper,  as  well  as  the  outlining  of  an 
occlusal  step  which  is  absolutely  imperative,  because  of  the 
more  secure  seating  and  rigidity  it  gives  a  filling  in  all  prox- 
imo-occlusal  cavities  in  molars  anrl  bi-cuspids  when  the  mar- 
ginal ridge  has  been  broken. 

Step  May  be  Omitted.     First;     In  cases  which  arc  to  re- 


158  ESSENTIALS  OF  OPERATIVE  DENTISTRY 

main  permanently  disarticulated  as  when  opposing  tooth  has 
been  lost. 

Second ;  When  the  proximating  tooth  is  to  be  absent  per- 
manently, thus  obviating  much  cutting  buccally  and  lingually 
in  extension  for  prevention,  as  the  remaining  walls  are  some- 
times strong  enough  to  give  sufficient  resistance  form  without 
the  added  step. 

Third :  When  the  proximating  tooth  is  to  be  absent  per- 
manently and  the  decay  is  in  the  gingival  third. 

Fourth :  In  proximal  decays  in  the  gingi\'al  third  fol- 
lowing excessive  gum  recession,    (so  called  senile  decay). 

Fifth :  When  for  any  reason  the  patient  should  be  shielded 
from  long  operations,  or  the  life  expectancy  of  either  the 
patient  or  the  individual  tooth  is  short. 

Sixth :  In  that  form  of  lower  bi-cuspids  with  a  well  de- 
fined and  perfect  transverse  ridge. 

Outline  of  Cavity  Proper.  The  outline  should  be  carried 
into  both  buccal  and  lingual  embrasures  until  the  excursions 
of  food  through  these  embrasures  will  sweep  the  margins  of 
the  completed  filling  for  its  entire  length.  This  extension 
will  result  in  carrying  the  outline  out  sufficiently  that  it  can 
be  seen  to  pass  under  the  gum  in  full  view.  (See  Figures  32 
and  23.) 


Fgure  22. 

A  Good  Rule  to  Follow  is  to  cut  sufficiently  that  a  chisel 
one  millimeter  in  width  will  pass  easily  from  the  embrasures 
to  the  open  cavity  when  dragging  the  cutting  edge  lightly 
over  the  free  margin  of  the  gum.  This  is  stated  as  a  general 
rule  only  there  being  circumstances  which  would  permit  fall- 
ing short  of  this  amount  of  space  and  yet  there  are  cases 
which  demand  a  greater  amount  of  cutting  to  fully  meet  the 
requirements  of  "Extension  for  prevention,"  due  to  oral  condi- 
tions and  dental  irregularities.     (Figure  22). 


MANAGEMENT  OF  CAVITIES— (Class  2) 


159 


Figure  23. 

Extensions  Gingivally.  The  cavity  outline  shoutcl  be  carried 
sub-gingivally  in  extension  for  prevention  when  from  other 
reasons  that  part  of  the  outHne  approaches  to  within  one  mil- 
limeter  of  the  gum  line.  The  application  of  this  rule  will 
invariably  cause  the  outline  to  go  beneath  the  gum  in  case 
the  gum  is  in  or  resumes  its  normal  position. 

If  there  is  reason  to  believe  that  it  will  return  to  its  normal 
position  this  fact  should  be  considered.  In  cases  of  permanent 
recession  it  is  better  to  stop  the  cavity  outline  midway  from 
contact  to  gum  line. 

Care  at  Axio-Gingival  Angles.  The  buccal  and  lingual 
portions  of  the  outline  should  be  carried  directly  gingivally 
and  be  made  to  join  the  gingival  portion  of  the  outline  by  the 
use  of  a  segment  of  a  small  circle.  The  use  of  a  large  circle 
here  is  a  most  common  error.  Investigation  of  fillings  will 
show  many  failures  wherein  a  large  circle  has  been  used  allow- 
ing the  external  outline  to  disappear  in  the  proximal  space 
before  it  has  disappeared  beneath  the  gum. 


ijlL, 


i 


Figure  24.     Sliowing   ideal    buccal,    lingual    and    gingival    outline. 


160 


ESSENTIALS  OF  OPERATIVE  DENTISTRY 


The  Gingival  Outline  should  be  a  straight  outline  except  in 
well  defined  and  high  gum  festoons,  when  it  may  be  made 
convex  to  the  occlusal. 

Forming  the  Step.  Place  a  small  round  bur  or  spade  drill 
against  the  axial  wall  at  the  dento-enamel  junction,  imme- 
diately below  the  central  fissure  and  undermine  the  enamel 
the  desired  distance  in  the  direction  of  the  central  axial  line  of 
the  tooth.  Here  apply  all  of  the  rules  and  methods  of  proce- 
dure given  in  the  formation  of  a  simple  occlusal  cavity.  Also 
remember  to  apply  the  rules  as  given  in  outline  form,  particul- 
arly as  to  resistance  form. 

Area  Included.  In  addition  to  the  above  it  is  a  safe  rule 
to  state  that  the  step  portion  should  involve  the  central  third  of 
the  occlusal  surface  bucco-lingually. 

Avoid  all  Angles  in  outline.  Care  should  be  taken  when 
using  the  step  that  its  union  with  the  cavity  proper  does  not 
show  in  the  outline  by  an  angle  at  their  junction.  Also  when 
not  using  the  step,  as  in  the  few  cases  cited,  care  should  be 
given  not  to  allow  the  axio-buccal  and  axio-lingual  line  angles 
to  meet  the  external  enamel  line.  These  line  angles  should 
be  stopped  before  they  approach  the  enamel  wall.  (See  Fig- 
ures 25  and  25a.) 


Figure  25.  Figure  25  A. 

Figure  25.     Showing  correct  occlusal  outline  without  angles. 

Figure  25  A.  Shows  incorrect  outline,  and  the  error  of  allowing 
line  angles  to  reach  the  external  enamel  line.  By  heavy  beveling  at 
three  points  this  is  improved,  as  shown  by  the  dotted  line. 


MANAGEMENT  OF  CAVITIES— (Class  2)  161 

Resistance  and  Retention  Forms.  To  reach  the  maximum 
of  these  forms  it  is  necessary  that  the  gingival  wall  be  flat 
and  laid  in  a  plane  at  right  angles  to  the  stress  of  mastication. 
The  g^ingival  wall  should  meet  the  axial  wall  at  an  angle  the 
least  bit  acute. 

The  grooving  of  the  gingival  wall  is  condemned. 

The  Buccal  and  Lingual  Walls  should  be  flat,  parallel  and 
meet  the  gingival  wall  at  least  at  right  angles  and  meet  the 
axial  wall  at  definite  and  acute  angles. 

The  Axial  Wall  should  be  convex  to  the  proximal  and  meet 
the  pulpal  wall  in  a  rounded  pulpo-axial  line  angle. 

The  Pulpal  Wall  should  be  laid  parallel  to  the  same  plane 
as  the  gingival  wall  and  slightly  broader  at  the  portion  most 
distant  from  the  cavity  proper.  This  gives  a  pulpo-distal  or 
pulpo-mesial  line  angle  of  a  little  greater  length  than  that  of 
the  pulpo-axial  line  angle,  resulting  in  a  dovetailed  effect  that 
is  most  efficient. 

Line  Angles.  The  line  angles  should  be  squared  out  and 
made  definite  by  the  use  of  small  hatchets  and  hoes  of  suit- 
able shapes  to  reach  the  desired  localities. 

The  gingio-buccal  and  gingio-lingual  line  angles  should  ex- 
tend from  their  corresponding  point  angles  to  the  dento- 
enamel  junction.  The  axio-buccal  and  axio-lingual  line  angles 
which  arise  in  the  same  point  angles  should  travel  occlusally 
one-third  to  one-half  the  height  of  the  axial  wall.  In  some 
rare  cases  where  the  pulpal  wall  is  low  from  decay  these  line 
angles  may  meet  the  axio-pulpal  line  angle.  A  failure  to  ob- 
serve this  rule  endangers  the  pulp  through  a  liability  of  cross- 
ing its  recessional  tracts. 

Convenience  Form.  In  the  making  of  a  cohesive  gold  fill- 
ing a  convenience  point  for  the  retention  of  the  first  piece 
of  gold  is  desirable.  This  is  best  accomplished  by  employing 
a  small  inverted  cone  bur,  say  number  thirty-three  and  one- 
half. 

The  flat  face  is  placed  on  the  gingival  wall  and  first  sunk 
to  one-third  its  depth  then  drawn  for  a  short  distance  occlus- 


162  ESSENTIALS  OF  OPERATIVE  DENTISTRY  ( 

i 
ally  along  the  axial  line  angle,  taking  dentine  slightly  at  the 
expense  of  both  axial  and  external  walls. 

With  the  making  of  a  plastic  filling  there  Is  no  need  of 
cutting  for  convenience  form  in  this  cavity. 

Inlays.  When  using  an  inlay  proper  convenience  form  is 
obtained  by  thorough  separation  and  causing  the  external 
walls  of  both  step  and  cavity  proper  to  meet  the  gingival 
and  pulpal  wall  at  slightly  obtuse  angles.  This  will  give 
draw  to  the  occlusal. 

Finish  of  Enamel  Walls.  The  enamel  walls  are  planed  to 
full  cleavage  and  the  margins  are  slightly  beveled.  All  but 
the  gingival  margins  may  be  done  with  the  chisel.  Special 
instruments  are  required  to  bevel  the  gingival  cavo-surface 
angle,  known  as  gingival  marginal  trimmers.  These  are  made 
rights  and  lefts  for  mesial  cavities,  and  rights  and  lefts  for 
distal  cavities  and  should  be  on  hand  in  two  sizes,  which 
would  result  in  eight  instruments  in  a  good  working  set. 

In  planing  the  gingival  enamel  wall  the  operator  should 
have  in  mind  the  gingival  inclination  of  the  enamel  rods  in 
this  locality. 

Toilet  of  the  Cavity  should  now  be  made  and  the  filling 
immediately  placed. 


PROXIMAL  CAVITIES  ENDANGERING  THE  PULP  Itic 


CHAPTER   XXVI 

Large  Proximal  Cavities  Endangering  tbe  Pulp. 
Description.  This  class  of  cavities  when  presented  show 
extensive  loss  of  dentine  in  the  proximal  wall.  The  marginal 
ridge  may  be  standing  or  it  may  have  been  broken  through 
stress  of  mastication.  In  some  cases  there  may  be  an  oc^ 
clusal  decay  in  the  central  fossa. 

Danger  of  Pulp  Exposure.  There  is  always  great  danger 
of  pulp  exposure  in  this  class  of  cases  and  this  fact  must  be 
continually  borne  in  mind,  during  the  procedure  of  prepara- 
tion. The  liability  is  increased  when  the  patient  is  young 
or  the  cusps  of  the  tooth  are  high  particularly  when  there 
exists  a  deep  pit  cavity  in  the  occlusal,  necessitating  a  low 
pulpal  wall.  With  young  patients  the  pulps  are  large  and 
the  horns  of  the  pulp  generally  extend  well  toward  the  cusps. 
Teeth  with  high  prominent  cusps  usually  have  long  pulp 
horns  and  they  should  be  considered  in  making  resistance, 
retention  and  convenience  forms. 

Outline  Form.  The  first  cuts  in  this  class  of  cavities 
should  be  with  the  chisel,  using  hand  pressure,  being  sure 
that  adequate  hand  and  finger  guard  has  been  obtained. 
This  precaution  is  essential  as  the  chisel  must  be  prevented 
from  reaching  the  sensitive  softened  dentine  within  the  cavity. 
Place  the  chisel  so  as  to  throw  the  chips  within  the  cavity. 
The  chisel  should  be  made  to  engage  only  a  small  portion  of 
enamel  at  each  cut.  Should  the  enamel  prove  resistant  the 
aid  of  the  mallet  may  be  resorted  to,  still  maintaining  a  firm 
finger  rest. 

Extension  for  Prevention  is  frequently  not  necessary  as  the 
extension  necessary  for  proper  resistance  form  will  carry  the 
cavity  the  required  distance  into  both  buccal  and  lingual  em- 
brasures.    However,  in   many  cases  the  decay  will  be  found 


164  ESSENTIALS  OF  OPERATIVE  DENTISTRY 

to  have  progressed  more  toward  one  embrasure  than  the 
other  which  necessitates  additional  cutting  for  prevention, 
in  the  direction  of  the  embrasure  least  approached  by  decay. 
This  should  be  to  the  fulfillment  of  the  rules  for  "extension 
for  prevention." 

Gingival  Outline.  The  gingival  outline  in  these  cases  will 
generally  be  under  the  free  margin  of  the  gum.  At  this  stage 
it  should  be  planed  with  the  enamel  hatchets  until  the  over- 
hanging enamel  is  broken  away  to  give  access  form  for  the 
free  passage  of  the  dam  and  ligature,  which  should  now  be 
placed  and  the  cavity  superficially  sterilized. 

Occlusal  Outline.  When  the  cavity  has  been  rendered  dry 
the  occlusal  outline  should  be  proceeded  with.  This  is  car- 
ried out  as  previously  given  in  the  forming  of  the  step  por- 
tion, and  the  full  satisfaction  of  the  rules  given  in  Outline 
Form,  Chapter  VII. 

Removal  of  Remaining  Decay.  This  is  an  instance  where 
the  sixth  step  in  cavity  preparation  comes  in  third  and  should 
now  be  cautiously  proceeded  with. 

Technic.  Large  spoons  should  be  used.  The  softened 
and  discolored  dentine  should  be  lifted  from  its  position  with 
as  little  pressure  pulp-wise  as  possible.  If  exposure  exists 
upon  its  removal,  pulp  treatment  for  devitalization  and  re- 
moval is  the  immediate  procedure.  If  exposure  does  not  ex- 
ist and  the  operator  has  reason  to  believe  that  that  organ  is 
healthy  the  pulpal  and  axial  walls  should  be  Hghtly  scraped 
with  large  spoon  excavators,  the  walls  disinfected  with  the 
favorite  drug  then  dried,  phenolized  and  dried  again,  the  lat- 
ter precaution  to  prevent  thermal  shock  to  the  pulp  during 
the  remaining  portion  of  cavity  preparation,  the  imperative 
necessity  for  which  is  shown  when  pain  is  induced  by  a  blast 
of  air  from  the  chip  blower. 

Resistance  and  Retention  Forms.  When  the  central  por- 
tion of  the  decay  is  found  to  be  deep  and  no  exposure  exists, 
the  pulpal  and  axial  walls  should  be  left  in  their  central  por- 
tions much  as  decay  has  left  them,  not  attempting  to  flatten 
these  walls  on  a  plane  of  their  greatest  depth  as  pulp  expo- 


PROXIMAL  CAVITIES  ENDANGERING  THE  PULP  165 

sure  may    result.       The  line    angles    surrounding  these  two 
walls  should  be  established  on  higher  levels. 

The  Gingival  Wall  should  be  made  flat  in  every  direction. 
This  is  accomplished  by  lowering  the  point  angles  root-wise  to 
the  level  of  the  central  portion. 

Convenience  Form.  Every  part  of  the  cavity  should  be 
examined  to  see  that  it  is  accessible  to  direct  force  in  the 
packing  of  the  filling  and  a  convenience  point  cut  in  each  of 
the  gingio-axio-lingual  point  angles. 

Pulp  Protection.  The  cavity  should  be  flooded  with  an 
efificient  non-irritating  disinfectant,  dried,  phenolized  and 
again  dried.  If  the  pulp  is  in  danger  it  should  be  protected 
as  described  in  Chapter  XVII. 

Finish  of  Enamel  Walls. 

The  enamel  walls  should  now  be  inspected,  corrected  for 
complete  cleavage  and  the  proper  cavo-surface  angle  estab- 
lished, using  for  this  a  keen  edged  chisel  and  a  light  hand  with 
a  planing  motion  parallel  with  the  external  enamel  line. 

For  Toilet  of  the  Cavity  use  a  few  blasts  of  air  from  the 
chip  blower,  followed  with  a  thorough  brushing  with  a  ball 
of  cotton  and  again  use  the  air  blast.  The  filling  should  be 
immediately  placed. 

Large  Proximal  Cavities  in  Devital  Teeth. 

In  the  management  of  this  class  of  cavities,  cutting  for 
resistance  to  stress  reaches  the  maximum  and  outline  is 
many  times  materially  extended  for  this  purpose  alone. 

Outline  Form,  With  Molars;  All  decay  and  softened  den- 
tine is  removed.  Many  times  this  will  leave  standing  an 
entire  cusp  of  unsupported  enamel  and  possibly  both  proxi- 
mal cusps  are  thus  unsupported.  In  such  cases  a  thin  edged 
carborundum  wheel  is  placed  on  the  occlusal  and  this  sur- 
face, ground  away  for  one  or  two  miljimeters,  extending  as  far 
toward  the  central  axial  line  to  just  beyond  the  buccal  or 
lingual  groove,  or  both  when  both  cusps  are  to  be  removed. 
This    grinding   process    is   carried   to   a   deeper   depth    in    the 


166 


ESSENTIALS  OF  OPERATIVE  DENTISTRY 


region  of  the  groove,  thus  resulting  in  a  step  which  gives  the 
filling  on  occlusal  seating.      (Figure  26.) 


.    Figure  26.     Giving  buccal  and  occlusal  views  of  cavity  in  second 
half  superior  molar  with  protected  cusp. 


With  Bi-Cuspids  this  buccal  or  lingual  outline  is  carried 
past  the  crest  of  the  cusp  involved  and  part  way  down  the 
opposite  slope.  This  procedure  results  in  disarticulating  the 
frail  enamel  wall  and  so  placing  the  metal  that  it  will  receive 
the  force  of  mastication.      (Figure  27.) 


fj 

^/^^"^"^ 

!xj^' 

Figure  27.     Giving  buccal  and  occlusal     views  of  second  left  su- 
perior bicuspid  with  protected  cusp. 


In  Mesio-Disto-Occlusal  Cavities  in  both  bi-cuspids  and 
molars,  which  are  devital,  the  occlusal  outline  should  include 
all  of  the  middle  third  and  be  farther  extended  about  one- 
half  of  the  buccal  and  lipgual  thirds.  Thus  two-thirds  of  the 
occlusal  surface  bucco-lingually  will  be  filling.  This  is  the 
minimum  amount  of  extension  for  favorable  cases.  (Figure 
38.) 


PROXIMAL  CAVITIES  ENDANGERING  THE  PULP 


16'; 


Figure    28.     M.    0.   D.    cavities    wliere    strong   dentinal    walls    are 
intact  and  the  occlusion  is  not  severe. 


In  Cases  of  Extreme  Frailty  the  entire  occlusal  surface  of 
lower  molars  and  bi-cuspids  should  be  replaced  with  filling 
of  at  least  one  millimeter  in  thickness.  With  upper  molars 
and  bi-cuspids  when  devital  and  very  frail  mesio-occluso- 
disto  cavities  the  lingual  cusp  should  be  remo\ed  for  one  or 
two  millimeters  and  replaced  with  filling  material.  (Figure 
29.) 


ijijiM^il} 


Figure  29.  Shows  treatment  necessary  with  extremely  frail  walls, 
devital  teeth.  Such  cases  have  been  most  frequently  crowned.  The 
inlay  is  now  much  used  in  this  class  of  cases,  outlining  as  above, 
both  buccally  and  lingually. 

Resistance  and  Retention  Forms  are  completed  by  squaring 
up  the  side  v/alls  and  sub-pulpal  wall,  making  a  box  shape  of 
the  pulj)  chamber,  with  fairly  definite  point  angles. 

Convenience  Form.  No  convenience  form  is  necessary  in 
this  class  of  cavities,  except  for  inlay  fillings,  which  will  be 
considered   later. 

Neglected  Access  Form.  Tn  cases  where  large  proximal 
cavities  are  of  long  standing  and  there  has  been  much  tipping 
to  the  proximal  of  one  or  both  teeth  preliminary  separation 
for  good  access  is  essential.     Without  this   preliminary  step 


168  ESSENTIALS  OF  OPERATIVE  DENTISTRY 

complete  contour  restoration  and  proper  contact  is  impossible. 
This  is  particularly  true  when  the  cavity  is  in  the  mesial  of  the 
first  molar.  Many  times  the  second  bi-cuspid  will  seem  to 
have  been  engulfed  within  the  molar  cavity.  In  cases  where 
preliminary  separation  for  obvious  reasons  is  impossible,  the 
evil  may  be  partly  overcome  by  the  free  cutting  away  of  both 
buccal  and  lingual  walls  until  the  filling  may  be  built  in  with 
a  proximal  surface  slightly  convex  to  the  proximal.  However, 
this  is  but  a  makeshift  of  a  filling  and  the  resulting  proximal 
space  will  always  be  defective. 

Toilet  of  the  Cavity.  In  large  decays,  particularly  if  the 
pulp  has  been  removed,  there  is  more  or  less  danger  in  leav- 
ing coatings  of  various  materials  clinging  to  the  walls.  Care 
should  be  taken  that  the  walls  are  scrupulously  clean.  It  is 
an  advantage  if  the  cavity  be  scrubbed  with  solvents  for  the 
suspected  coatings.  The  cavity  should  then  be  dried,  the  en- 
amel walls  planed  and  the  cavity  freed  of  all  debris. 

Over  desiccation.  Particular  care  should  be  had  not  to  use 
excess  desiccation  in  pulpless  teeth  as  this  will  render  them 
brittle  and  easy  of  fracture  when  put  to  use. 


MANAGEMENT  OF  CAVITIES— (Class  3)  169 


CHAPTER  XXVII. 

Management  of  Proximal   Cavities  in   Incisors  and   Cuspids 
Not  Involving  the  Angle,  Class  Three. 

Definition.  Class  three  cavities  are  those  in  the  proximal 
of  incisors  and  cuspids  where  it  is  not  necessary  to  restore 
the  incisal  angle.  The  angle  may  be  allowed  to  remain  when 
the  enamel  at  the  angle  is  supported  by  sound  dentine  to  an 
extent  which  will  give  it  sufificient  resistance  to  prevent  frac- 
ture under  stress  of  mastication. 

Exception.  The  conditions  and  requirements  are  a  little 
different  with  cavities  on  the  distal  of  superior  cuspids  from 
those  on  the  other  proximal  surface  of  the  six  anterior  teeth 
and  will  be  given  a  special  description. 

General  Form  of  Class  Three.  Cavities  in  incisor  proximal 
surfaces  differ  from  all  others  in  that  they  are  in  the  surface 
of  teeth  of  a  triangular  form  and  the  cavities  of  necessity 
must  be  of  this  form,  rather  than  the  typical  box  shape  in 
the  other  classes  of  cavities. 

Location  of  Primary  Decay.  The  location  of  primary  de- 
cay, as  with  all  contact  decay,  is  just  gingivally  from  contact 
point.  This  will  result,  as  a  rule,  in  the  seat  of  initial  decay 
being  about  midway  from  the  incisal  edge  to  the  gingival 
outline.  As  the  plates  of  enamel,  both  labial  and  lingual,  are 
quite  heavy  and  usually  removed  from  direct  stress,  there  will 
generally  be  considerable  loss  of  dentine  while  the  enamel 
walls  are  yet  intact.  The  decay  may  be  apparently  small, 
yet  reflected  light  by  the  use  of  mouth  mirror  will  show  a  dis- 
coloration of  a  well  defined  area.  The  curved  tine  of  an 
explorer  may  or  may  not  enter  from  either  the  labial  or 
lingual  embrasure. 

Opening  the  Cavity.  P.athe  the  surfaces  of  all  the  anterior 
teeth  in  that  jaw  with  water  to  free  them  of  micro-organisms 


170 


ESSENTIALS  OF  OPERATIVE  DENTISTRY 


and   gummy   material,   particularly   the   gingival   border,    and 
apply  the  mechanical  separator. 

Gaining  Access.  With  a  small  straight  chisel  of  about  one 
millimeter  in  width  cut  away  the  enamel  edge,  throwing  the 
chips  into  the  cavity.  Adequate  finger  rest  must  be  secured 
before  applying  the  chisel  and  only  small  portions  of  enamel 
engaged  at  each  application,  as  a  failure  in  either  respect  may 
result  in  checking  the  enamel  to  a  greater  extent  than  de- 
sired. When  sufficient  entrance  has  been  made  to  the  cavity 
to  admit  the  instrument,  the  remaining  enamel  margins  may 
be  planed  from  this  direction  until  a  ligature  will  pass  from 
the  incisal  to  the  gingival  line.  Where  time  will  permit  the 
case  should  be  packed  for  preliminary  separation  as  described 
in  Chapter  VI.  If  immediate  separation  and  filling  is  to  be 
practiced  the  rubber  dam  should  be  adjusted  and  the  mechan- 
ical separator  placed  and  tightened  to  a  snug  pressure.  The 
separator  should  be  tightened  from  time  to  time  until  the 
required  separation  is  obtained.  The  approximate  space  re- 
quired is  one-half  of  one  millimeter  where  only  one  cavity 
exists  in  the  proximal  and  a  full  millimeter  in  cases  where 
two  cavities  exist.  These  measurements  are  taken  from  the 
cavo-surface  angle  of  the  completed  cavity  at  its  closest  ap- 
proach to  the  proximating  tooth. 


Figure  30. 


Figure  31. 


FiguTes    30   and   31    show   labial    and   lingual   outline    of   cavities 
class   3. 


Outline  Form.  As  these  cavities  are  located  in  the  most 
exposed  portion  of  the  mouth  aesthetic  reasons  demand  as 
little  cutting  as  possible  consistent  with  the  demands  for  per- 


MANAGEMENT  OF  CAVITIES— (Class  3)  171 

manency.  However,  it  is  a  good  rule,  in  outlining  cavities 
class  three,  to  extend  in  all  directions  until  when  the  filling  is 
completed  the  entire  cavity  outline,  not  covered  with  gum 
tissue,  is  in  full  view  of  the  operator.  Figure  30  and  31.  As 
stated  before,  excessive  cutting  to  obtain  this  condition  may  be 
obviated  by  proper  separation. 

Gingival  Outline,  should  be  carried  mid-way  between  con- 
tact and  gum  line,  and  farther  extended  to  go  under  the  gum 
when  it  approaches  to  within  one  millimeter  of  the  gum. 
Great  care  should  be  exercised  to  square  out  both  labial  and 
lingual  axio-gingival  angles,  carrying  them  sufficiently  into 
these  embrasures  that  the  cavity  margins  may  be  in  full  view 
as  they  pass  under  the  gum. 

The  Incisal  Outline,  should  be  carried  incisally  until  the 
margin  of  the  filling  will  be  permanently  in  view,  with  a 
space  sufficient  to  admit  of  the  free  use  of  the  toothbrush  on 
the  margin.  This  would,  in  many  instances,  carry  the  margin 
beyond  the  incisal  edge  and  make  a  class  four  cavity  and 
only  avoided  by  separation  and  the  filling  of  the  cavity  to 
slightly  excess  contour. 

The  Labial  Outline  should  be  carried  into  the  labial  em- 
brasure until  the  margins  are  in  full  view.  The  enamel 
should  be  split  away  until  full  length  rods  are  obtained.  On 
account  of  the  exposed  location  of  these  cavities  the  aesthe- 
tic reasons  demand  as  little  cutting  labially  as  possible.  As 
this  margin  is  practically  removed  from  the  stress  of  occlu- 
sion it  is  not  essential  that  the  enamel  be  supported  by  den- 
tine in  every  instance.  However,  care  should  be  taken  that 
the  rods  are  full  length  and  that  all  rods  are  removed  where- 
in there  has  been  a  backward  decay  as  shown  by  a  whitened 
powder  like  condition  at  their  dentinal  ends. 

Additional  Extension  for  aesthetic  reasons  is  sometimes  re- 
quired in  the  labial  embrasure.  This  is  more  often  true  in 
the  mesial  cavities  wherein  the  teeth  are  angular  in  form  and 
present  surfaces  that  are  fpntc  flat,  resulting  in  a  very  square 
or  prominent  mesio-labial  angle.  In  such  cases  the  outline 
should  be  carried  over  the  angle  and  into  the  labial  surface. 


172  ESSENTIALS  OF  OPERATIVE  DENTISTRY 

that  the  metal  may  be  brought  into  the  light,  otherwise  the 
completed  filling  will  have  the  appearance  of  a  decay  or  dark 
spot  on  the  tooth. 

The  Lingual  Outline  must  be  carried  into  the  lingual  em- 
brasure sufficiently  to  be  brought  into  full  view  in  all  cases. 

In  the  case  of  teeth  of  rounded  form  this  will  not  always 
include  the  proximal  marginal  ridge.  In  teeth  of  a  squared 
form  and  prominent  lingual  ridges  the  marginal  ridges  should 
be  included  and  the  outline  carried  along  the  axial  slope  of 
the  ridge.  The  fact  that  many  cases  will  show  a  lingual  arti- 
culation and  occlusion  on  the  lingual  marginal  ridges  of  upper 
incisors,  will  bring  demands  for  including  within  the  cavity 
the  major  portion  of  these  ridges,  unless  supported  by  a  good 
bulk  of  sound  dentine.  The  failure  to  recognize  this  fact  on 
the  part  of  many  operators  is  responsible  for  the  loss  of  a 
large  percent  of  this  class  of  fillings. 

Resistance  Form.  No  special  resistance  form  other  than 
that  just  given  is  required  in  this  class  of  cavities. 

Retention  Form.  When  this  order  in  the  preparation  has 
been  reached  attention  should  be  directed  to  the  incisal  angle, 
particularly  in  the  larger  cavities,  as  cases  will  be  met  with 
in  which  it  will  be  found  necessary  to  remove  the  incisal 
angle  to  secure  proper  resistance  form.  Thus  looking  to  the 
incisal  first  will  decide  this  point  early  in  the  procedure. 

The  Incisal  Line  Angle  should  meet  the  axial  wall  at  at  least 
a  right  angle.  In  cases  where  this  line  angle  is  short  as  found 
in  shallow  cavities  the  incisal  line  angle  should  meet  the  axial 
wall  at  a  slightly  acute  angle.  It  is  not  necessary  to  make  a 
convenience  angle  at  the  incisal  point  angle. 

The  bevel  angle  on  the  gingival  wall  becomes  the  fulcrum. 
It  is  only  necessary  that  the  distance  from  this  point  to  the 
incisal  point  angle  be  greater  than  that  from  the  same  point 
on  the  gingival  wall  to  the  most  external  portion  of  the  in- 
cisal line  angle.  The  more  shallow  the  cavity  in  class  three 
the  more  acute  must  be  the  incisal  point  angle. 

Other  Point  Angles.  The  gingio-axio-labial  and  the  gin- 
gio-axio-lingual  point  angles  are  now  carried  into  the  dentine 


MANAGEMENT  OF  CAVITIES— (Class  3)  173 

at  the  expense  of  both  axial  and  external  walls,  care  being 
given  not  to  groove  the  gingival  wall. 

Line  Angles.  Line  angles  are  made  with  small  hatchets 
and  hoes  of  suitable  sizes,  say,  one-third  to  one-half  milli- 
meter in  width,  with  edges  that  are  keen  and  whose  corners 
are  well  defined,  not  having  been  rounded  through  careless 
sharpening  or  wear. 

The  Axio-Labial  Line  Angle  is  chased  and  sharpened  for 
its  entire  length,  making  it  particularly  definite  as  it  ap- 
proaches each  of  the  point  angles. 

The  Axio-Lingual  Line  Angle  is  made  definite  for  one 
millimeter  in  each  direction  from  its  two  point  angles,  omit- 
ting the  central  portion,  as  this  precaution  will  give  added 
resistance  form  to  the  lingual  wall.  The  sharpening  of  these 
line  angles  is  best  accomplished  by  engaging  the  instrument 
in  the  dentine  the  desired  distance  from  the  point  angle  and 
cutting  to  the  angle. 

The  Gingio-Axial  Line  Angle  should  be  well  defined  to 
make  the  gingival  wall  meet  the  axial  at  a  definite  angle,  but 
should  in  no  way  be  a  ditch  or  groove. 

The  Gingio-Labial  and  Gingio-Lingual  Line  Angles  should 
be  cut  away  from  their  point  angles  out  to  and  end  at  the 
dento-enamel  junction.  As  the  general  form  of  the  cavity 
is  that  of  a  triangle  these  angles  will  always  be  acute. 

Gingival  Wall.  The  gingival  wall  should  be  flat  in  every 
direction. 

Axial  Wall.  The  axial  wall  should  be  left  as  decay  has 
left  it  in  the  central  portion  and  all  additional  cutting  should 
tend  to  make  it  take  on  the  form,  in  miniature,  of  the  surface 
of  the  tooth  in  which  the  decay  has  originated.  A  disregard 
of  this  rule  will  endanger  the  pulp,  whereas  if  the  axial  wall 
is  left  as  convex  as  possible  the  pulp  has  all  possible  protec- 
tion.     (Figure   32.) 

Labial  and  Lingual  Walls.  These  walls  should  be,  as  far 
as   possible,   of   the    same    thickness    for    their    entire    length, 


174  ESSENTIALS  OF  OPERATIVE  DENTISTRY 

which  will  result  in  their  inner  surfaces  being  of  the  same 
contour  as  the  external  surface  of  the  tooth. 


Figure  32.  Showing  flat  gingual  wall  class  3.  Also  convexity  of 
axial  wall  except  in  central  portion,  where  decay  has  isogressed  pulp- 
wise.     Dotted  line  shows  danger  of  flattening  axial  wall. 

Convenience  Form.  Two  convenience  points  are  advisable 
in  this  class  of  cavities,  cut  in  each  of  the  gingio-axio-labial 
and  the  gingio-axio-lingual  angles,  beginning  the  filling  in  the 
latter  angle. 

Removal  of  Remaining  Decay,  At  this  point  inspect  the 
dento-enamel  junction  for  softened  dentine.  Also  the  entire 
axial  wall  should  be  scraped  with  large  spoons  for  the  re- 
moval of  the  last  of  the  softened  dentine,  the  cavity  disin- 
fected, dried,  phenolized  and  again  dried.  Pulp  protector 
should  be  applied  when  indicated. 

Finish  of  Enamel  Walls.  The  enamel  walls  should  be 
planed  to  full  cleavage,  with  suitable  instruments  of  chisel 
edges,  not  forgetting  the  incisal  and  gingival  inclination  of 
the  rods  in  these  locations.  Bevel  the  cavo-surface  angle, 
give  the  cavity  its'  toilet  and  immediately  place  the  filling.. 

In  Devital  Cases.  When  the  axial  wall  has  been  lost  by 
reason  of  pulp  removal  the  entire  pulp  chamber  should  be 
filled  with  cement  of  a  very  light  yellow  color  or  even  a  white 
cement  may  be  used.  In  extremely  frail  teeth  this  may  be 
only  partially  filled  and  the  remaining  portion  used  for  re- 
tention. 

Cavities  in  the  Distal  of  Superior  Cuspids.  On  account  of 
the  peculiar  articulation  of  the  lingual  surface  of  superior 
cuspids  this  cavity  has  been  left  for  separate  consideration. 

Access  is  an  easy  matter  as  the  decay  is  in  the  most  prom- 


MANAGEMENT  OF  CAVITIES— (Class  3)  175 

inent  part  of  the  distal  surface  and  a  little  work  with  the 
chisel  gives   access  to   the   cavity. 

Outline  Form.  In  outlining  the  cavity  proper,  what  has 
been   said   about   class   three  should  be   followed  here. 

As  to  the  lingual  outline  (see  distal  filling  in  cuspid  Figure 
30  and  31)  and  that  of  the  step  particular  attention  must  be 
paid  to  so  placing  the  margins  as  to  remove  them  as  much  as 
possible  from  the  stress  of  articulation. 

The  Step.  The  lingual  step  is  added  to  this  cavity  as  it 
materially  assists  in  retention,  resistance  and  convenience 
forms. 

In  the  laying  of  the  walls  of  the  step  portion  the  particulars 
are  carried  out  much  as  though  the  lingual  surface  of  the 
cuspid  was  an  occlusal  surface,  as  next  to  the  occlusal  sur- 
face it  receives  the  greatest  stress  in  articulation. 

Axial  Walls.  It  will  be  seen  that  this  cavity  has  two  axial 
walls.  That  in  the  cavity  proper  is  the  axial,  while  that  in 
the  step  is  termed  the  lingual  axial  wall. 

The  Lingual  Axial  Wall  should  be  placed  on  a  plane  paral- 
lel with  the  lingual  surface  of  the  tooth.  Its  surrounding  line 
angles  should  be  laid  just  below  the  dento-enamel  junction. 

Convenience  Form  in  this  cavity  is  pretty  well  secured  by 
the  addition  of  this  lingual  step,  as  the  filling  is  then  easily 
built  in  from  the  lingual  direction.  Both  gingival  point 
angles  in  the  cavity  proper  should  be  made  convenience 
angles  as  well  as  the  axio-gingio-mesial  point  angle  in  the 
step  portion. 


176  ESSENTIALS  OF  OPERATIVE  DENTISTRY 


CHAPTER  XXVIII. 

Management  of  Proximal  Cavities  in  Incisors  Involving  the 
Angle.     Class  Four. 

Definition.  Cavities  class  4  are  those  in  which  the  incisal 
angle  has  either  been  lost  or  can  not  be  safely  retained.  The 
decision  as  to  its  restoration  is  of  most  vital  importance.  To 
cut  the  angle  from  nearly  every  incisor  which  has  a  proximal 
decay  is  little  short  of  malpractice  while  at  the  same  time  ta 
attempt  to  save  those  not  wholly  and  adequately  supported  by 
dentine  is  to  invite  many  disastrous  failures. 

Conditions.     Demanding  frequent  Angle  Restoration. 
First.     When  contact  is  in  the  incisal  third.     In  such  cases 
a  very  small  decay  will  involve  all  of  the  dentine  to- 
ward the  incisal  angle. 
Second.     Incisors    which    have    long    flat    proximal    surfaces. 
Such  teeth  will  show  a  line  of  decay  extending  gingio- 
incisally   and    may   entirely   weaken   the    incisal   angle 
before  the  pulp  is  in  danger. 
Third.     The  pulp  may  be  involved  and  its  removal  materially 
lessens   the    resistance   of    supporting    dentine   at   the 
angle. 
Fourth.     The   angle   under   consideration   may  be   so  located 
that  it  is  frequently  required  to  stand  great  stress  in 
service.     This  is  a  point  that  must  not  be  overlooked 
as  an  angle  which  stands  well  exposed  must  bear  much 
greater   and   oft  repeated   force   than   an    angle  which 
does  not  occlude  or  can  not  be  brought  into  articula- 
tion. 
Difference    Between    Mesial    and    Distal    Surfaces.       The 
above  four  conditions  will  be   more  frequently  met  with   in 


MANAGEMENT  OF  CAVITIES— (Class  3) 


177 


mesial  surfaces,  hence  the  mesial  angles  are  in  greater  danger 
and  more  often  require  restoration. 

Plans  of  Angle  Restoration.  There  are  four  general  plans 
of  restoring  the  incisal  angle  which  are  worthy  of  considera- 
tion. Many  plans  have  been  advanced  from  time  to  time, 
but  the  four  given  below  seem  to  have  remained  in  favor. 

First  Plan.  Anchorage  by  under  cutting  the  incisal  edge. 
This  plan  is  indicated  in  teeth  of  rather  thick  incisal  edge  and 
rather  short  and  stocky  as  they  have  a  greater  body  of  den- 
tine near  the  angles  upon  which  to  depend.  (See  A  and  Al 
in  Figures  33  and  34.) 


Figure  33.     Showing  labial  outline  of  cavities  class  4.     A  is  plan 
1.     B  plan  2.     C  plan  3  and  D  plan  4. 


Figure  34.  Showing  lingual  outline  of  cavities  class  4.  Al  is 
plan  1.  Bi  is  plan  2.  CA  plan  3  and  Di  plan  4,  which  is  a  comhina- 
tion  of  2  and  3  in  that  it  has  both  incisal  and  lingual  steps. 


As  a  rule  the  horns  of  the  pulp  in  such  teeth  are  well  re- 
tracted, at  least  in  adult  mr)iiths,  and  there  is  less  danger  of 
pulp  exposure  as  compared  with  the  teeth  of  thin  edges  and 


178  ESSENTIALS  OF  OPERATIVE  DENTISTRY 

angular  outline.  If  this  plan  has  been  decided  upon  the 
ca\ity  should  be  cut  well  to  the  gingival  particularly  at  the 
gingival  angles,  in  some  cases  to  the  extent  that  the  gingival 
wall  is  made  convex  to  the  incisal. 

The  Gingival  Point  Angles  should  be  deep  and  well  defined 
at  the  expense  of  both  gingival  and  axial  walls.  This  is 
particularly  true  of  the  axio-gingio-lingual  angles,  to  protect 
against  the   torsion   strain. 

To  Assist  the  Incisal  Angle,  To  resist  the  tipping  strain 
both  the  labial  and  lingual  walls  should  be  slightly  grooved 
along  the  axio-labial  and  axio-lingual  line  angles  much  in  the 
same  way  as  with  large  class  3  cavities. 

The  Labial  Outline,  should  so  proceed  that  the  completed 
filling  will  be  of  about  equal  width  for  its  entire  length  ex- 
cept that  as  it  approaches  the  incisal  edge  it  should  be  slightly 
curved  to  the  axial. 

A  Rule  for  Labial  Outlines.  All  cavity  outlines  in  incisal 
angle  restorations  should  curve  to  the  axial  as  they  approach 
the  incisal  edge.  The  nearer  this  outline  approaches  the  cen- 
tral axial  line  of  the  tooth  the  greater  should  be  the  curve. 
When  the  central  axial  line  is  reached  by  a  cavity  outline, 
the  same  should  then  be  extended  to  involve  the  opposite 
angle.  There  are  exceptions  to  the  above  rule  but  maximum 
resistance  to  stress  is  only  thereby  obtained.     (Figure  35.) 


Figure  35.  Shows  tlie  necessary  increased  curve  to  the  axial 
at  the  incisal  edge  the  nearer  the  labial  approaches  the  central  line 
of  the  tooth. 

The  Necessity  for  Curving  to  the  Axial.  When  approach- 
ing the  incisal  edge  curve  to  the  axial  that  the  last  rods  at 
the    cavo-surface    angle   may   be    adequately    supported.     A 


MANAGEMENT  OF  CAVITIES— (Class  3) 


179 


large  percent  of  fillings  where  this  precaution  has  been  neg- 
lected fail,  showing  a  primary  fault  due  to  the  breaking  away 
of  the  enamel  at  this  point.      (Figure  36.) 


Figure  36.     Shows  the  failures  resulting  from  a  disregard  of  the 
curve  to  the  axial  at  the  incisal  edge. 

The  Incisal  Outline  as  it  crosses  the  incisal  edge  should 
have  in  its  center  a  curve  toward  the  axial  caused  by  a  slight 
groove  in  the  center  of  the  dentine.  This  groove  which  ends 
at  this  point  in  the  cavity  outline  should  originate  at  the  ex- 
ternal end  of  the  incisal  line  angle.  If  there  is  sufficient 
dentine,  and  there  generally  will  be  in  the  class  of  cases  call- 
ing for  this  plan  of  restoration,  this  groove  is  of  best  service 
if  it  be  a  flattened  groove  and  made  with  a  small  hoe  or 
hatchet.        ("Figure  37.) 


Figure  37.     Cavity  class  4,  plan  1,  showing  outline  as  it  crosses 
incisal  edge. 


The  Lingual  Outline,  should  be  the  same  as  for  large  class 
three  except  in  the  incisal  third  when  it  should  curve  to  the 
axial  even  more  rapidly  than  the  labial  outline  and  for  a 
longer  distance,  resulting  in  cutting  away  more  enamel  from 
the  lingual  than  is  removed  by  the  labial  outline.  This  is 
made  necessary  from  the  fact  that  all  stress  is  from  the 
lingual. 

With  Lower  Incisors,  the  reverse  is  true  and  it  is  necessary 
to  remove  slightly  more  of  the  labial  enamel  in  angle  restora- 


180  ESSENTIALS  OF  OPERATIVE  DENTISTRY 

tion,  a  fact  which  materially  mars  these  teeth  from  an  aesthe- 
tic point  of  view.  Fortunately  we  have  comparatively  few 
angles  to  restore  on  lower  incisors,  but  when  they  are  pre- 
sented the  fact  must  be  borne  in  mind  that  they  receive  the 
major  portion  of  stress  from  the  inciso-labial  direction. 

Second  Plan  of  Angle  Restoration  Class  4. 

The  second  plan  of  restoration  (See  B  and  Bl  Figures  33  and 
34)  is  indicated  in  teeth  that  are  of  medium  thickness  particu- 
larly if  they  are  of  angular  build  or  have  a  direct  contact  on  the 
incisal  edge  either  in  occlusion  or  articulation,  and  consists 
in  the  addition  to  plan  one  of  what  is  termed  the  incisal  step. 
The  cavity  proper  is  prepared  the  same  as  has  been  outlined 
in  plan  one  up  to  the  forming  of  the  step. 

The  Incisal  Edge,  is  cut  away  with  a  narrow  edged  car- 
borundum stone  extending  the  cutting  toward  the  opposite 
angle  past  the  middle  lobe  of  the  tooth,  yet  not  to  involve  the 
next  labial  groove.  In  this  position  the  incisal  outline  avoids 
both  the  center  of  primary  calcification  and  t'le  point  of 
coalescence,  two  weak  places  in  enamel  construction.  The 
cutting  should  be  more  at  the  expense  of  the  lingual  side  of 
the  tooth,  resulting  in  the  lingual  plate  of  enamel  being 
shortened  more  than  the  labial  plate  from  one-half  to  one 
millimeter. 

The  Depth  of  This  Step,  inciso-gingivally,  will  depend  upon 
the  thickness  of  the  cutting  edge,  and  the  probable  stress  it 
will  receive.  The  thinner  the  edge  and  the  greater  the  prob- 
able stress,  the  deeper  must  be  the  step.  The  majority  of 
cases  will  show  not  to  exceed  one  millimeter  of  gold  on  the 
labial  in  the  step  portion. 

Technic  of  Cutting.  A  small  round  bur  is  then  used  to  cut 
a  groove  in  this  newly  formed  pulpal  wall,  near  the  dento- 
enamel  junction  next  to  the  lingual  plate  of  enamel.  The 
lingual  enamel  is  then  removed  with  a  chisel  thus  carrying 
that  portion  of  the  pulpal  wall  to  a  lower  level.  Continue 
this  process  till  it  is  at  least  one-half  millimeter  to  one  milli- 
meter lower  than  the  labial  portion  of  the  pulpal  wall.     This 


MANAGEMENT  OF  CAVITIES— (Class  3)  181 

leaves  the  major  portion  of  the  dentine  supporting  the  labial 
plate  of  enamel. 

The  Resulting  Point  Angle  in  the  Step  Portion,  should  be 
deepened  and  made  acute  at  the  expense  of  all  surrounding 
walls.  This  will  place  it  in  just  the  right  position  to  resist 
stress  from  the  probable  source. 

This  Second  Plan  is  Particularly  Indicated,  in  cases  of 
much  wear  on  the  incisal  due  to  what  is  called  "end  to  end" 
bite.  However,  in  such  cases  all  of  the  exposed  dentine  on 
the  incisal  edge  should  be  included  in  tlip  step  and  it  is  not 
necessary  to  remove  much  of  either  of  the  labial  or  lingual 
plates  of  enamel.  In  such  cases  the  step  portion  should  be  re- 
tentive throughout  as  it  is  liable  to  be  worn  away  by  subse- 
quent wear  growing  thinner  from  year  to  year  hence  the 
necessity  of  retentive  form  from  cavo-surface  angte  to  the 
base  line  angles. 

Third  Plan  of  Angle  Restoration  Class  4. 

This  plan  is  the  addition  to  plan  one  of  the  lingual  step, 
rSee  C  and  Cl  Figures  33  and  34.  It  is  particularly  indicated 
in  cases  of  long  incisors  which  are  quite  thin  labio-lingually 
and  subjected  to  a  long  sweep  of  the  lower  incisors  in  the 
movements  of  articulation,  or  what  is  spoken  of  as  the  "scis- 
sors bite." 

Also  Indicated,  in  cases  where  the  axial  wall  extends  out  to 
the  enamel  edge  on  the  lingual  thus  removing  the  lingual 
wall. 

The  Labial  Outline  is  the  same  as  with  the  first  plan  of 
restoration.  The  step  is  formed  on  the  lingual  by  cutting 
away  the  enamel  from  the  lingual  surface  of  the  tooth  toward 
the  central  axial  line,  for  a  distance  of  from  one  to  two  milli- 
meters at  the  incisal  edge. 

As  the  gingival  is  approached  the  cutting  is  narrowed  to  a 
point  where  the  marginal  ridge  may  be  crossed  at  right  angles 
to  meet  the  gingival  portion  of  the  outline.  This  will  form  a 
V  shapcfl  axial  wall  of  dentine  facing  the  lingual.  There 
should  be  cut  a  flat  floored  groove  in  this  dentine  parallel 
with   the  remaining  enamel  wall   ending  in   the   gingio-axio- 


182  ESSENTIALS  OF  OPERATIVE  DENTISTRY 

lingual  angle  which  should  be  an  acute  convenience  angle. 
The  plan  gives  great  resistance  to  stress  from  lingual  pres- 
sure. 

Fourth  Plan  in  Angle  Restoration  Class  4.  Consists  of  re- 
sorting to  all  of  the  features  of  resistance  and  retention  em- 
bodied in  plans  two  and  three  by  combining  both  the  lingual 
and  incisal  step.  (See  D  and  Dl  Figures  33  and  34.)  Each 
of  these  have  been  fully  described  and  the  method  of  cutting 
both  steps  to  the  same  should  not  prove  hard  to  accomplish. 

By  this  plan  the  maximum  resistance  and  retention  forms 
are  secured  with  the  minimum  loss  of  dentine.  It  must  be 
remembered  that  resistance  to  stress  is  good  in  proportion 
to  the  amount  of  securing  dentine  retained,  hence  it  should 
be  sparingly  cut  away;  whereas  the  removal  of  enamel  to  lay 
bare  dentine  wherein  to  lay  anchorage  is  only  harmful  from 
a  co.smetic  stand  point  and  not  of  much  force  when  taken 
away  from  a  surface  not  in  view  as  is  the  case  when  we  cut 
away  a  portion  of  the  lingual  plate. 


MANAGEMENT  OF  CAVITIES— (Class  5) 


183 


CHAPTER  XXIX. 

Management  of  Cavities  in  the  Gingival  Third  Class  5 
Gingival  Third  Cavities  Differ  from  all  other  cavities  in  the 
teeth  in  that  they  originate  on  perfectly  smooth  surfaces 
generally  without  flaw  in  enamel  formation  and  without 
covering  of  any  kind,  or  to  state  it  more  concisely  there 
seems  to  be  no  p:edispos'!!g  cause. 

Their  Prevention  is  an  easy  matter,  as  the  accumulation  of 
sordes  which  is  the  sole  exciting  cause,  is  unprotected  and  of 
easy  access  to  the  brush  so  that  patients  with  this  class  of 
decay  are  paying  the  penalty  for  the  careless  neglect  of  the 
simplest  forms  of  oral  cleanliness.  With  these  facts  before 
us  it  becomes  the  duty  of  every  practitioner  to  fully  advise 
the  patient  of  the  neglect  of  their  mouths  in  this  particular 
locality,  in  an  effort  to  check  farther  destruction. 

The  Tendency  to  Spread  in  the  Enamel  is  a  characteristic 
of  this  class  of  cavities.  (Figure  38).  They  usually  origi- 
nate near  the  center  of  the  buccal  surface  near  the  free  margin 
of  the  gum  and  seldom  stop  till  they  have  extended  both 
mesially  and  distally  nearly  to  the  angles.  The  fact  that  the 
encroachment  seldom  reaches  the  angle  in  the  external 
enamel  decay,  is  a  point  to  be  considered  in  the  study  of  ex- 
tension for  prevention  in  this  class  of  cavities.  It  appears 
that  when  the  outline  is  carried  quite  to  the  angle  that  sec- 
ondary caries  rarely  occurs. 


Figure  38. 


184 


ESSENTIALS  OF  OPERATIVE  DENTISTRY 


The  Gingival  Outline  should  be  laid  below  the  gum  line 
for  its  entire  length  till  the  angles  are  reached  when  it  should 
emerge  from  beneath  the  gum  at  a  right  angle  to  the  free  mar- 
gin of  the  gum. 

The  Occlusal  or  Incisal  Outline  should  be  carried  to  a  re- 
gion of  sound  enamel.  Where  this  extension  does  not  carry 
this  outline  farther  than  one  millimeter  from  the  free  margin 
of  the  gum  farther  extension  should  be  made.  With  teeth 
surrounded  by  a  heavy  gum,  particularly  if  there  seems  to  be 
a  condition  of  hypertrophy  present,  the  occlusal  outline 
should  be  laid  at  least  two  millimeters  from  the  border  of  the 
gum.  Figure  39  shows  a  safe  outlining  of  cavities  shown  in 
Figure  38. 


Figure  39. 


Retention  Form.  Retention  is  secured  by  squaring  out 
the  four  point  angles.  The  axial  wall  should  generally  be 
left  as  decay  has  left  it  in  the  central  portion.  Any  subse- 
quent cutting  should  be  of  such  a  nature  as  would  tend  to 
make  it  convex  to  the  external,  or  so  to  speak  the  miniature 
of  the  tooth's  surface  in  which  it  is  being  cut.  An  effort  to 
cut  a  flat  axial  wall  mesio-distally  will  many  times  endanger 
the  pulp  and  is  unnecessary  as  these  cavities  need  no  re- 
sistance form. 

In  Large  Buccal  Decay  often  times  the  gum  has  so  grown 
into  and  filled  the  cavity  that  the  adjustment  of  the  clamp 
and  rubber  dam  is  difficult  or  impossible.  In  such  cases  if 
the  pulp  is  not  involved  much  assistance  is  secured  by  pack- 
ing the  cavity  full  of  gutta-percha  base  plate  allowing  it  to 
crowd  well    down  upon   the   gum.     In  a   few   days   the   gum 


MANAGEMENT  OF  CAVITIES— (Class  5) 


185 


will  have  receded  or  been  absorbed  sufficiently  to  permit  of 
convenient  access. 

If  the  Pulp  is  Involved  and  requires  extirpation  make  the 
application  of  the  devitalizing  agent,  covering  this  with 
amalgam  which  should  fill  the  cavity.  Care  should  be  taken 
that  the  gingival  wall  has  been  planed  to  a  solid  condition. 
During  this  operation  dryness  may  be  obtained  by  the  assist^ 
ance  of  cotton  rolls. 

When  case  returns  the  clamp  will  ride  on  the  amalgam 
at  the  gingival  and  access  to  the  pulp  may  be  had  through 
the  upper  portion  of  the  amalgam.  After  the  pulp  canals 
have  been  filled  the  dam  may  be  removed,  the  remainder  of 
the  amalgam  excavated  and  cavity  preparations  proceeded 
with  as  well  as  the  placing  of  an  amalgam  filling,  under  dry 
conditions  by  the  use  of  cotton  rolls. 

If  Gold  is  to  Be  Used  the  gold  inlay  is  clearly  indicated  as 
producing  the  best  results  with  the  least  tax  upon  patient 
and  operator. 


Figure  40.     Shows   ideal   cavities  for  gold  inlays   when  they  are 
deep.     This  filling  should  supplant  the  amalgam  so  commonly  used. 


With  Labial  Cavities  in  the  gingival  third  the  Hatch  clamp 
will  expose  nearly  every  case  presented  and  render  access 
not  difficult  for  the  introduction  of  a  cohesive  gold  filling.  In 
cases  of  extensive  gum  recession  on  labial  exposures  the  por- 
celain inlay  is  clearly  indicated  and  is  considered  in  the 
chapters  on  that  subject. 


186  ESSENTIALS  OP  OPERATIVE  DENTISTRY 


CHAPTER  XXX 

Management    of    Abraded    Surfaces,     Occlusal    and     Incisai 

Class  6. 

Definition.  Class  6  includes  the  group  of  cavities  made 
necessary  for  the  repair  of  injuries  to  the  teeth  through  the 
loss  of  a  portion  of  their  articulating  surfaces  as  the  result 
of  wear.  The  condition  is  abnormal  and  the  extent  of  the 
destruction  of  tooth  substance  is  by  no  means  in  proportion 
to  the  amount  of  use  to  which  the  teeth  have  been  subjected. 
However  it  will  be  noticed  in  mouths  with  teeth  of  short 
cusps,  and  particularly  if  the  incisors  occlude  directly  upon 
the  incisai  edge  that  there  is  an  abnormal  amount  of  lateral 
motion  in  the  act  of  articulation,  and  in  such  mouths  we  find 
the  maximum  loss  of  tooth  substance  at  any  given  age. 

Cause  Not  Wholly  Clear.  Yet  that  friction  is  the  sole 
cause  for  this  lesion  can  not  be  demonstrated,  as  the  surfaces 
thus  affected  do  not  show  the  exact  impression  of  the  oppos- 
ing teeth,  neither  is  this  condition  always  delayed  till  ad- 
vanced years.  Cases  will  be  occasionally  met  with  in  the 
mouths  of  people  in  middle  life  showing  the  advanced  stages 
of  this  trouble. 

At  the  same  time  locations  will  be  found  on  the  occlusal 
surfaces  of  teeth  which  at  one  time  must  have  been  in  ar- 
ticulation but  are  so  far  lost  and  seemingly  worn  away  that 
they  could  not  be  brought  into  occlusion. 

It  would  seem  from  a  study  of  a  great  number  of  cases  that 
there  must  be  some  causes  predisposing  and  exciting  not  yet 
understood.  It  is  not  improbable  that  the  cause  is  a  fault  in 
tooth  structure,  not  so  much  in  the  constituents  of  the  tooth 
as  in  the  lack  of  strength  in  their  combination.  This  con- 
clusion would  seem  plausible  from  the  fact  that  teeth  sim- 
ilarly situated  and  of  the  same  chemical  analysis  are  affected 


MANAGEMENT  OF  ABRADED  SURFACES— (Class    6)  187 

to  a  different  degree  by  even  slight  friction.  The  bond  of 
union  does  not  seem  to  be  so  strong. 

The  Object  in  Filling  or  in  making  a  cavity  to  fill  is  to  per- 
manently check  the  loss  of  tooth  substance  by  entirely  cover- 
ing the  affected  surface  with  a  substance  that  will  resist  the 
full  force  of  mastication. 

Occlusal  Surfaces.  In  occlusal  surfaces,  particularly 
molars  showing  the  first  stages  of  general  erosion,  early  inter- 
ference is  advised.  As  soon  as  a  cusp  is  lost  it  should  be  re- 
stored and  if  possible  built  high  with  gold  preferably  an 
alloy  of  gold,  either  platinized  foil  or  a  cast  inlay  of  gold 
alloy. 

This  Early  Restoration  of  cusps  to  their  full  height  will 
tend  to  restrict  the  lateral  motion  of  the  mandible  in  masti- 
cation, which  seems  to  be  a  factor  in  this  dissolution. 

Cavity  Preparation.  These  Cavities  should  be  prepared 
as  class  one  and  should  be  retentive  throughout. 

If  the  Major  Portion  of  the  Occlusal  Surface  of  a  single 
molar  is  affected  the  whole  occlusal  surface  should  be  low- 
ered about  one  millimeter  and  the  same  restored  with  a  cast 
inlay  or  some  times  termed  an  onlay.  This  is  advised  from 
the  fact  that  the  occlusal  side  of  the  filling  may  better  fit  the 
surface  of  the  occluding  teeth.  This  may  and  probably  will 
necessitate  the  devitalization  of  this  individual  tooth  when 
the  pulp  chamber  should  be  utilized  for  anchorage. 

If  Contact  Points  have  been  reached  by  this  cutting,  a 
mesio-occlusio-distal  cavity  is  imperative. 

When  Wear  is  General  opening  the  bite  to  the  extent  of 
about  one  millimeter  is  preferable  to  cutting  away  any  more 
tooth  substance  than  is  necessary  for  firm  foundation  and  a 
correct  outline.     (Figure  41 .) 

With  Incisal  Abrasion,  if  the  wear  is  not  excessive,  the 
building  on  of  the  "shoe"  or  covering  the  entire  incisal  end 
of  the  tooth  with  platinized  gold  is  the  best  practice.  The 
g-old  inlay  is  also  of  service  which  is  treated  of  in  the  chapters 
on  inlays. 


188 


ESSENTIALS  OF  OPERATIVE  DENTISTRY 


When  there  is  excessive  incisal  wear  opening  the  bite  to 
practically  normal  is  indicated  using-  gold  for  the  posterior 
teeth  and  the  porcelain  crown  for  the  anterior. 


g^ 

i 

W       w 

Fi^re  41.     Showing  the  necessary  amount  of  metal  for  adequate 
protection  to  abraded  surfaces,  when  opening  the  bite. 


The  Entire  Enamel  Edge  on  the  occlusal  and  incisal  must 
be  covered  with  a  protecting  layer  of  metal  as  with  these 
teeth  the  bond  of  union  seems  to  be  very  weak,  particularly 
at  the  dento-enamel  junction  and  will  chip  away  if  not  wholly 
Protected  from  the  force  of  mastication. 


CAVITY  PREPARATION  FOR  GOLD  INLAYS  189 


CHAPTER  XXXI 

Cavity  Preparation  for   Gold   Inlays. 

Definition.  An  inlay  is  a  body  placed  within  a  previous- 
ly prepared  excavation.  As  applied  to  the  filling  of  teeth  it 
refers  to  the  process  whereby  the  filling  is  inserted  into  the 
cavity  of  a  tooth  in  one  piece  and  retained  there,  by  the  as- 
sistance of  cement. 

The  Materials  in  most  common  use  are,  porcelain,  pure  gold,. 
alloys  of  gold  as  well  as  alloys  of  base  metals. 

The  Indications  for  a  Gold  Inlay  are  first  in  large 
contour  restorations,  as  there  is  a  material  saving  of 
both  time  and  energy  on  the  part  of  both  patient  and  operator. 
Such  cases  particularly  with  posterior  teeth  which  are  fre- 
quently crowned  with  the  shell  gold  crown  with  its  almost 
universally  irritating  band,  when  the  inlay  could  be  of  great- 
er service. 

Second.  When  it  is  difficult  to  maintain  dry  conditions  for 
a  long  period  of  time  about  a  ca\'ity,  as  with  large  gingival 
cavities  in  molars  and  bicuspids. 

Third.  When  there  are  extensive  occluding  surfaces  to  be 
restored.  It  is  much  easier  to  cast  a  correct  contour  than  to 
build  up  such  cases  with  the  plugger  point  which  is  largely 
guess  work  when  the  rubber  dam  is  in  position. 

Fourth.  When  it  is  desired  to  put  in  a  number  of  fillings 
in  a  given  short  time.  In  such  cases  the  operator  can  make 
the  wax  models,  and  engage  the  help  of  the  laboratory  in 
completing  the  fillings  while  he  is  still  busy  with  other  fillings 
at  the  chair. 

Fifth.  When  the  necessary  force  to  properly  condense  a 
cohesive  gold  filling  is  not  permissible,  as  with  loosened 
teeth,  or  invalid  patients. 


190  ESSENTIALS  OF  OPERATIVE  DENTISTRY 

Sixth.  When  it  is  desired  to  use  a  filling  as  the  anchorage 
of  a  bridge. 

Gold  Inlays  Are  Not  Indicated  in  small  shallow  cavities. 

The  Cavity  Preparation  for  a  gold  inlay  does  not 
materially  differ  from  that  which  has  already  been  advised 
in  the  preceding  chapters.  It  is  possible  to  construct  an  in- 
lay without  change  for  nearly  every  cavity  which  has  been 
correctly  prepared  to  receive  a  cohesive  gold  fillings.  How- 
ever if  the  order  of  precedure  is  slightly  rearranged  the 
operation  is  simplified. 

This  Change  in  the  Order  would  be  to  put  retention  form 
last,  attending  to  that  part  of  the  cavity  preparation,  after 
the  model  has  been  made  and  just  before  setting  the  inlay. 

In  cases  where  this  has  not  been  done,  or  the  cavity  is 
naturally  retentive,  the  retention  angles  should  be  tempo- 
rarily covered,  as  will  later  be  described,  while  making  the 
model. 

The  Order  of  Procedure  for  Inlays  would  then  be  as  fol- 
lows : 

1.  Gain  access. 

2.  Outline  form. 

3.  Resistance  form. 

4.  Convenience    form. 

5.  Removal  of  remaining  decay. 

6.  Finishing  enamel  walls. 

7.  Toilet  of  the  cavity  and 

8.  Retention  form,  which  is  given  as  the  fourth  order  in 
other  forms  of  fillings. 

Gaining  Access  for  inlay  filling  is  the  same  as  that  with 
other  fillings  as  far  as  surgical  procedure  is  concerned.  No 
more  tooth  substance  should  be  cut  away  on  this  account. 

When  using  preliminary  separation  for  access  there  should 
in  most  cases  of  class  2  and  3  cavities,  be  more  room  secured 
as  this  will  materially  assist  in  getting  a  correct  wax  model 
as  well  as  aid  in  the  process  of  placing  the  inlay. 

Resistance  Form  for  Inlays  should  receive  the  same  careful 
consideration  as  given  for  other  fillings.     Weakened  enamel 


CAVITY  PREPARATION  FOR  GOLD  INLAYS  191 

walls  should  be  protected  not  only  from  the  subsequent  force 
received  in  stress  but  from  the  stress  of  setting  the  inlay. 
Flat  seats  for  all  inlays  is  imperative.  The  usual  steps  in 
class  2  and  4  are  called  for  as  an  important  factor  to  resist 
the  tipping  strain. 

Convenience  Form  for  Inlays  should  not  be  practiced  to  ex- 
cess. Xo  convenience  points  are  required.  The  major  por- 
tion of  convenience  form  should  be  gained  through  separation 
preferably  slov/  separation. 

The  Finishing  of  the  Enamel  Walls  will  necessarily  come 
in  at  this  point  as  all  cutting  of  the  external  outline  of  the 
cavity  must  be  completed  before  proceeding  to  make  the 
model.  The  only  change  advisable  is  that  the  cavo-surface 
angle  should  be  more  obtuse,  and  the  bevel  angle  should  not 
be  as  deeply  buried  which  results  in  a  thinner  metal  edge. 

This  will  assist  in  burnishing  the  margins  to  a  closer 
adaptation  in  the  final  finish. 

The  Toilet  of  the  Cavity  for  Gold  Inlays.  Herein  lies  the 
greatest  weakness  in  inlay  methods.  No  cavity  margin  is 
surgically  clean  after  it  has  been  moistened  or  been  in  contact 
with  the  inlay  wax  model. 

After  the  model  has  been  formed  and  removed  our  methods 
will  not  permit  of  again  planing  the  cavity  surfaces  and  parti- 
cularly the  margins,  which  is  the  only  way  to  render  them 
entirely    clean. 

Hence  we  are  forced  to  wash  the  cavity  walls  just  before 
setting  the  inlay  with  solvents  of  the  substances  which  have 
contaminated  them.  Without  going  into  detail,  it  is  advised 
that  the  cavity  be  thoroughly  scrubbed  with  chloroform,  then 
absolute  alcohol,  as  a  second  cavity  toilet  and  immediately 
flow  the  cavity  with  the  cement  introducing  the  inlay  under 
dry  conditions. 

Line  of  Approach.  In  inlay  work  the  cavities  should  be 
approached  from  the  direction  in  which  they  are  to  receive 
stress  during  service. 

In  withdrawing  the  wax  ni'jdcl  and  when  the  inlay  is  placed, 
each     should     travel     parallel      with     a     line     drawn     from 


192  ESSENTIALS  OF  OPERATIVE  DENTISTRY 

the  seat  of  the  cavity  to  the  load.  This  is  good  practice  with 
any  filhng,  but  is  more  essential  with  the  gold  inlay  than  the 
cohesive  gold  filling,  for  we  do  not  have  the  assistance  of  the 
elasticity  of  the  dentine  in  retention  made  possible  by  the  use 
of  the  wedging  principle  in  the  manipulation  of  cohesive 
gold. 

Preparation  of  cavities  class  1.  Of  the  cavities  of  this  class 
calling  for  gold  inlays  only  the  large  occlusal  in  molars  are 
of  importance.  Small  pit  and  fissure  cavities  are  more  quickly 
and  easily  filled  by  other  methods. 

Outline  Form.  In  large  occlusal  cavities  the  outline  should 
be  so  carried  as  to  avoid  eminences,  as  the  crest  of  marginal 
ridge. 

When  this  is  reached  on  the  buccal  or  lingual  the  outline 
should  include  the  marginal  ridge  and  at  least  one  millimeter 
of  the  axial  wall  approached.  All  deep  grooves  should  be  in- 
cluded.    The  curves  should  be  as  generous  as  possible. 

Resistance  Form.  The  same  rule  applies  as  to  flat  seat  as 
with  other  fillings.  In  addition  weak  lateral  walls  must  be 
protected  from  articulation  by  a  layer  of  gold. 

Retention  Form  should  come  in  for  consideration  after  the 
model  is  made  and  consists  in  sharpening  the  pulpal  angles. 

Preparation  of  Cavities  Class  II.  Large  proximal  cavities 
in  molars  and  biscupids  are  most  successfully  handled  with 
this  method  of  filling. 

Acess-  Preliminary  separation  is  of  the  greatest  service 
here  and  should  be  a  general  practice  as  much  cutting  for  con- 
venience form  is  avoided,  and  better  contact  secured. 

Outline  Form.  The  outline  for  inlay  filling  is  much  the 
same  as  for  other  methods.  Care  should  be  taken  that  the 
buccal  and  lingual  walls  are  parallel,  particularly  the  enamel 
portion  of  these  walls,  as  the  wax  model  must  move  directly 
to  the  occlusal  in  exist.  It  is  equally  essential  in  Inlays  that 
angles  and  sharp  turns  in  outline  be  avoided. 

Resistance  Form.  Flat  gingival  and  pulpal  walls  are  also 
demanded.  Weakened  buccal  and  lingual  cusps  should  be  re- 
placed. 


CAVITY   PREPARATION  FOR  GOLD  INLAYS  19S 

Finish  of  Enamel  Walls.  The  planing  of  the  marginal  bevel 
should  be  a  little  more  generous  than  for  cohesive  gold. 

Retention  Form.  The  same  general  retention  should  be 
given  these  cavities  as  for  cohesive  filHng  and  should  be  dealt 
with  after  model  is  made.  When  the  cavity  on  account  of 
decay  is  naturally  retentive  or  has  undercuts  these  are  tempo- 
rarily filled  and  overcome  by  covering  the  retentive  portion 
of  the  cavity  with  some  substance,  as  temporary  stopping  or 
wax  of  a  different  color  than  that  used  in  making  the  model. 

In  Cavities  Class  Three  the  gold  inlay  is  seldom  indicated. 
An  exception  may  be  made  in  those  which  are  large  and  have 
from  decay  lost  their  entire  lingual  wall. 

Access  is  of  a  necessity  from  the  lingual. 

The  Outline  is  the  same  as  though  a  cohesive  filling  was 
to  be  made.  Care  should  be  taken  that  the  labial  bevel  is  laid 
in  the  same  plane  as  the  travel  of  the  wax  model  to  exit,  else 
this  portion  of  the  model  will  be  distorted  in  removal. 

In  Cavities  Class  Four  the  use  of  the  inlay  should  be  largely 
restricted  to  devital  cases  and  a  pin  in  the  pulp  canal  used 
for  additional  strength. 

The  method  of  construction  will  be  found  in  the  following 
chapter.  The  first  and  second  plans  of  angle  restoration  are 
preferable    for   inlays. 

The  Only  Change  from  that  given  for  cohesive  gold  for  the 
cavity  preparation  is  the  order  of  procedure  as  previously 
stated,  that  of  leaving  retentive  form  out  of  the  consideration 
till  the  model  has  been  made. 

The  Enamel  Walls  should  be  well  beveled,  which  will  in 
no  way  hinder  the  removal  of  the  model.  Model  should 
make  exit  to  the  incisal  with  a  slight  lingual  travel. 

Cavities  Class  Five,  Of  this  class  the  large  buccal  cavities 
call  for  gold  inlays,  in  which  they  are  the  ideal  filling,  and 
should  largely  replace  the  amalgam  so  commonly  used. 
Figure  40  represents  a  case  which  is  ideal  for  gold  inlays 
particularly  if  the  cavities  arc  deep. 

The    Occlusal    Wall.     The   axio-occlusal    angle   should   be 


194  ESSENTIALS  OF  OPERATIVE  DENTISTRY 

slightly  obtuse,  while  the  axio-mesial  and  distal  angles  may 
be  nearly  a  right  angle.  This  will  permit  the  model  to  tip  to 
the  buccal  in  exit,  though  the  gingio-axial  angle  be  acute. 

Cavities  Class  Six.  The  restoration  of  abraded  surfaces 
with  the  gold  inlay  is  good  practice,  inasmuch  as  it  is  possible 
to  effectually  protect  these  surfaces  from  further  destruction 
with  the  minimum  amount  of  cutting.  As  is  the  case  with 
the  other  forms  of  filling  the  surface  co\'ered  should  be  gener- 
ous. If  only  one  tooth  is  to  be  treated  with  this  filling  the 
amount  of  tooth  substance  cut  away  will  be  about  the  same  as 
the  quantity  of  gold  in  the  inlay. 

However  if  the  bite  is  to  be  raised  on  most  or  all  teeth  the 
cutting  is  very  slight  and  only  enough  to  properly  cleave  and 
bevel  the  enamel  margins.  Figure  41  represents  such  a  case 
wherein  the  inlay,  or  pinned  inlay  was  used  on  the  molars 
and  bicuspids.     Cohesive  platinized  gold  on  six  anterior. 

In  vital  cases  either  incisal,  lingual  or  occlusal,  the  retention 
should  be  made  by  the  introduction  of  short  pins,  iridio- 
platinum  preferred,  through  a  matrix  of  pure  gold,  and  cast 
the  contour. 

In  devital  cases  a  single  large  pin  should  be  used,  or  the 
model  may  be  so  made  as  to  occupy  a  part  of  the  pulp  cham- 
ber in  lieu  of  the  pin. 


MAKING  AND  SETTING  OF  GOLD  INLAY  195 


CHAPTER  XXXII. 

The  Making  and  Setting  of  a  Gold  Inlay. 

In  discussing  the  methods  of  making  any  filling  particularly 
the  gold  inlay,  one  must  bear  in  mind  that  the  best  practice  of 
today  may  be  obsolete  tomorrow.  In  this  chapter  an  attempt 
is  made  to  bring  out  only  the  most  popular  methods  at  this 
time,  fully  aware  that  while  this  volume  is  in  press  busy 
minds  ^re  evolving  new  plans  which  may  prove  of  better  ser 
vice. 

The  Objects  of  the  Inlay.  The  objects  of  the  inlay  are  to 
protect  the  cement  which  covers  the  cavity  walls  and  to  re- 
store  lost   contours. 

If  cement  was  permanent  in  the  mouth  when  exposed  to 
wear  and  dissolving  agents,  there  would  be  no  call  for  inlays 
which  are  really  only  made  to  protect  the  cement.  It  is 
therefore  of  the  utmost  importance  that  the  inlay  completely 
cover  the  cement  by  a  perfect  adaptation  at  the  cavity  margins 
and  that  it  be  so  constructed  that  it  will  maintain  this  close 
adaptation. 

In  choosing  the  method  of  construction  in  each  case  the 
marginal  adaptation  should  be  considered  and  the  one  selected 
which  promises  the  greatest  perfection. 

History.  The  gold  inlay  is  one  of  the  oldest  forms  of  filling 
in  fact  is  the  oldest  as  proven  by  excavation  in  the  Orient. 
Teeth  in  the  skulls  of  mummies  have  been  found  wherein 
cavities  have  been  crowded  full  of  lead,  with  the  probable 
intent  to  check  decay.  Even  in  modern  times  the  inlay  has 
always  been  practiced  more  or  less,  and  has  become  more 
popular  as  time  goes  on.  As  compared  with  the  making  of  a 
cohesive  gold  filling,  they  are  infinitely  easier,  and  the  history 
of  our  college  clinics  shows  that  the  beginner  attains  a  pass- 
ing degree  of  success  with  the  gold  inlay  long  before  he  is 


196  ESSENTIALS  OF  OPERATIVE  DENTISTRY 

able   to   understand  and  successfully  bring  to   bear  many  of 
the  qualities  of  cohesive  gold. 

Method  Using  Model  Entirely  of  Wax.  The  cavity  should 
be  prepared  as  for  any  other  metal  filling  except  that  the  re- 
tention form  should  be  omitted.  In  case  decay  has  so  left 
the  cavity  that  it  is  naturally  retentive  by  having  excavated 
undercuts  these  should  be  filled  with  some  substance  which  is 
no  part  of  the  model,  and  which  is  easily  removed  before 
setting  the  inlay.  The  substances  used  to  temporarily  remove 
the  retentive  form,  are  cement,  temporary  stopping,  modeling 
compound  and  wax,  the  preference  being  with  the  wax. 

This  wax  should  be  of  a  decidedly  different  color  than 
that  of  which  the  model  is  made. 

The  Filling  of  the  Undercuts  should  be  made  to  dry  cavity 
walls,  and  with  the  wax  quite  warm  to  insure  its  adhering, 
that  it  may  not  leave  the  walls  to  distort  the  model.  The 
difference  in  the  color  of  wax  used  will  make  the  detection 
of  any  particles,  which  may  adhere  to  the  model  and  their 
removal  easy. 

By  a  little  study  and  the  judicious  use  of  the  above  method 
much  cutting  for  convenience  form  may  be  obviated  and 
many  seemingly  difficult  cases  rendered   quite   simple. 

The  Making  of  the  Model.  After  the  retentive  form  has 
been  removed,  the  cavity  should  be  flooded  with  water  of  ord- 
inary temperature.  This  will  render  the  wax  within  the 
cavity  sufficiently  hard  not  to  yield  under  the  force  neces- 
sary to  introduce  the  model  wax.  It  will  also  prevent  the 
portions  of  wax  from  adhering.  The  wax  for  the  model 
should  then  be  softened,  preferably  by  the  slow  dry  heat 
method.  The  wax  should  be  sufficiently  plastic  to  permit  of 
molding  when  manipulated  in  the  fingers,  care  being  taken 
that  the  wax  is  not  folded  upon  itself  as  the  portions  will  not 
adhere.  Wax  so  folded  is  liable  to  part  at  the  folds  and  come 
away  from  the  cavity  in  sections.  The  wax  should  be  gently 
shaped  so  that  it  can  be  introduced  into  the  cavity  in  such 
manner  as  to  come  in  contact  with  the  base  walls  or  floor  of 
the  cavity  first,  then  by  slow  continued   pressure   for  about 


MAKING  AND  SETTING  OF  GOLD  INLAY  197 

fifteen  seconds  made  to  expand  till  it  entirely  fills  the  cavity, 
overflowing  all  margins. 

If  the  inlay  is  to  replace  any  portion  of  the  occluding  sur- 
face the  operation  should  be  done  with  the  rubber  dam  off. 
The  patient  is  requested  to  close  the  teeth  to  full  occlusion, 
slowly.  It  must  be  remembered  that  the  casting  wax  is  only 
semi-plastic  and  moves  very  slowly,  hence  the  best  impression 
is  obtained  by  moderate  continued  force,  giving  the  sluggish 
wax  time  to  flow.  Wax  is  really  quite  elastic  when  confined 
and  when  the  pressure  from  the  bite  is  removed  the  wax  will 
spring  back,  the  least  bit,  so  that  the  cast  inlay  will  be  too 
high   when   set. 

To  overcome  this  it  is  good  practice  to  have  the  patient 
again  close  the  teeth  to  occlusion  with  one  layer  of  rubber 
dam  over  the  occlusial  surface  of  the  model  requesting  them 
to  maintain  the  pressure  for  some  seconds,  the  elasticity  of 
the  rubber  dam  overcoming  the  elasticity  of  the  wax.  This 
will  do  away  with  much  grinding  after  fitting  the  inlay  to 
position.  The  model  should  then  be  carved  to  full  contour 
restoration  and  correct  external  surface  form,  and  the  wax 
thoroughly  burnished  around  the  entire  cavity  outline. 

Ideal  Conditions  Are  Obtained  when  the  wax  slightly  over- 
laps the  cavo-surface  angle  at  all  points  in  the  outline  about 
one-tenth  of  a  millimeter. 

This  will  give  sufficient  bulk  for  correct  finishing.  The 
model  completed  it  is  well  to  insert  the  tine  of  an  explorer 
to  the  depth  of  about  one  or  two  millimeters  in  a  convenient 
position  for  removal  and  best  into  the  greatest  body  of  the 
model.  The  tine  should  be  removed  the  model  chilled,  with 
cold  water,  the  tine  reinserted  into  the  previously  made  hole 
and  the  model  gently  pushed  to  exit. 

The  Placing  of  the  Sprue  Wire.  While  the  model  is  still 
carried  on  the  tine  of  the  explorer,  the  sprue  wire  should  be 
warmed  and  inserted.  In  selecting  the  position  for  the  wire, 
care  should  be  taken  that  a  location  is  chosen  so  that  the  con- 
tour of  the  surface  of  the  model  leaves  the  sprue  wire  in  all 
directions  at  an  obtuse  angle.     A  neglect  of  this  point  will  oc- 


198  ESSENTIALS  OF  OPERATIVE  DENTISTRY 

casionally  result  in  imperfect  casts  near  the  sprue  former. 
The  tine  of  the  explorer  should  now  be  withdrawn  and  the 
resulting  hole  sealed  by  contacting  the  warm  end  of  small 
instrument. 

A  good  instrument  for  such  work  is  the  flattened  end  of  a 
large  pulp  canal  cleaner  or  broach. 

Giving  the  Wax  Model  Retention  Form.  Portions  of  the 
model  should  now  be  removed,  preferably  by  the  use  of  the 
heated  hollow  needle,  in  such  manner  as  to  give  the  cement 
an  ample  grasp  upon  the  inlay,  and  should  be  equal  to  or 
more  than  the  amount  of  retention  of  which  the  cavity  in  the 
tooth  is  capable.    The  model  is  then  ready  for  investment. 

Method  of  Using  Wax  Model,  Pin  Attached.  This  method 
is  of  service  when  for  any  reason  it  is  desired  to  have  the 
maximum  amount  of  retention,  as  for  instance  when  the  inlay 
is  to  serve  as  an  abutment  for  a  bridge. 

In  such  cases  the  teeth  will  generally  be  devital  and  a  por- 
tion of  the  pulp  cavity  used  for  the  reception  of  the  pin. 

Placing  the  Pin.  The  cavity  should  be  first  freed  from  re- 
tentive form  as  described  above,  using  either  cement,  tempo- 
rary stopping,  modeling  compound,  or  wax,  then  the  open- 
ing made  in  the  pulp  canal  to  receive  the  pin  which  is  placed 
in  position,  with  a  light  coat  of  sticky  wax  on  outer  end. 
The  pin  should  be  long  enough  to  reach  well  into  the  body  of 
the  wax  model  and  should  be  of  iridio-platinum.  No  other 
material  will  stand  the  heat  of  casting  the  inlay  without  alloy- 
ing or  losing  its  rigidity. 

The  wax  for  the  model  is  then  manipulated  the  same  as 
though  no  pin  had  been  used.  When  model  is  withdrawn  the 
pin  should  come  away  with  the  wax :  In  case  it  does  not 
withdraw  the  pin  from  the  tooth  and  seal  it  into  tfie  hole  it 
has  left  in  the  wax  model,  the  whole  model  should  be  returned 
to  position  to  insure  alignment.  Withdraw  model  after  chill- 
ing and  all  is  ready  for  investment. 

Method  of  Using  Pure  Gold  Matrix  With  Pin  Soldered  on, 
Casting  the  Contour.  This  method  is  advised  as  most  prac- 
tical in  cavities  class  4,  first  plan,    when  teeth    are    devital. 


aiAKING  AND  SETTING  OF  GOLD  INLAY  199 

This  simplifies  angle  restoration  and  provides  ample  resist- 
ance form,  without  the  cutting  of  either  the  incisal  or  lingual 
step.  In  such  cases  the  alignment  of  the  pin  must  be  perfect 
else  the  inlay  will  not  go  to  proper  place.  The  soldering  of 
the  pin  to  a  gold  matrix  gives  the  desired  security  during  the 
processes  of  removing,  and  investment.  The  cavity  prepara- 
tion is  the  same  as  for  cohesive  gold  except  the  convenience 
angles.  The  pin  is  fitted  to  a  portion  of  the  pulp  canal  as  pre- 
viously given.  A  sheet  of  pure  gold  32  or  34  gauge  is  selected 
of  sufficient  size  to  more  than  cover  the  cavity  by  about  two 
millimeters.  Partially  burnish  this  to  the  cavity  but  only 
sufficiently  to  show  the  cavity  outline  in  the  gold. 

Punch  a  hole  in  the  proper  position  to  receive  the  pin  but 
smaller  than  the  pin  which  should  be  15  or  16  gauge.  Place 
matrix  in  position  and  crowd  pin  through  the  hole  to  position. 
Scribe  the  pin  just  external  to  the  gold  matrix,  remove  and 
solder  as  nearly  in  correct  position  as  possible  without 
stopping  to  invest,  using  22K  solder. 

Only  very  small  amount  of  solder  will  be  needed  or  should 
be  used,  care  being  taken  that  it  is  all  flowed  close  to  the  pin 
to  prevent  stiffening  the  matrix.  All  should  then  be  returned 
to  the  cavity  and  the  gold  reburnished  to  a  perfect  fit  of  the 
entire  cavity  outline. 

It  is  necessary  to  burnish  the  gold  only  partially  into  the 
deep  recesses  of  the  cavity  as  the  pin,  if  of  Irido-platinum  will 
be  sufficient  anchorage.  This  can  be  made  to  equal  that  fre- 
quently relied  on  for  an  entire  crown.  This  model  must  move 
to  the  incisal  for  exit  and  if  the  matrix  is  burnished  to  con- 
tact with  the  axial  wall  it  will  become  fixed.  The  matrix 
should  be  burnished  to  a  complete  fit  of  the  gingival  wall 
which  should  be  flat  and  well  squared  into  the  labial  and 
lingual  angles. 

Making  the  Wax  Contour.  The  matrix  and  attached  pin 
are  removed,  anrl  the  desired  contour  built  up  by  flowing  the 
wax  to  position  with  a  spatula,  trying  the  whole  model  to 
place  in  the  cavity  to  guide  in  the  restoration.  When  com- 
plete, chill  the  wax,  remove  and  all  is  ready  for  investment. 


200  ESSENTIALS  OF  OPERATIVE  DENTISTRY 

To  Restore  Occlusal  and  Incisal  Surfaces  lost  from  abra- 
sion with  inlays  where  the  tooth  is  vital,  nothing  answers  the 
purpose  better  than  the  following  method.  The  outline  of  the 
surface  to  be  covered  is  established.  Small  holes  are  drilled 
to  convenient  depths  in  safe  locations  of  sufficient  size  to  re- 
ceive a  20  gauge  Irido-platinum  pin.  Three  or  four  pins  are 
required  for  molars  and  two  or  three  for  bicuspids  or  incisors. 
A  pure  gold  matrix  32  or  34  gauge  is  then  burnished  to  an 
approximate  fit.  The  positions  of  the  holes  in  the  tooth  will 
be  outlined  in  the  gold.  The  matrix  should  be  pricked  at 
these  points  with  a  sharp  pointed  instrument  smaller  than  the 
pins.  One  pin  is  inserted  and  should  protrude  occlusally 
through  the  matrix  for  a  short  distance. 

This  pin  and  matrix  are  then  removed  and  attached  with 
solder  applying  the  solder  to  the  occlusal  side  of  the  matrix. 
The  matrix  should  be  returned  to  the  tooth  and  another  pin 
placed  and  attached  in  the  same  way,  repeating  till  all  pins 
are  in  position,  when  the  matrix  should  receive  a  final  bur- 
nishing. The  wax  contour  is  then  added  as  before  described, 
the  pattern  replaced  and  articulation  secured  in  the  mouth 
and  finally  trimmed  to  desired  contour.  The  wax  should  then 
be  chilled  and  the  entire  model  removed  and  invested. 

Method  of  Sweating  the  Contour. 

Advantages.  The  advantages  of  this  older  method  of  mak- 
ing an  inlay  still  exists  where  the  inlay  is  to  cover  consid- 
erable surface  and  is  very  shallow.  Such  inlays  are  generally 
termed  "onlays."  This  method  is  advised  from  the  fact  that 
models  of  such  nature  will  seldom  maintain  exact  form  during 
the  process  of  removing  and  investment  unless  a  gold  matrix 
is  used. 

If  the  gold  matrix  is  used  it  is  difficult  to  cast  a  thin  layer 
of  gold  over  the  entire  surface  of  this  matrix  and  get  good 
margins  unless  a  large  quantity  of  gold  is  melted  to  make  the 
cast  in  which  case  the  gold  matrix  is  very  liable  to  be  entirely 
fused,  which  will  not  give  the  best  results.  Speed  is  also  a 
factor  in  this  instance.     Many  times  an  onlay  can  be  flowed 


MAKING  AND  SETTING  OF  GOLD  INLAY  201 

to  the  desired  thickness  in  much  less  time  than  that  required 
to  invest  and  cast. 

Making  the  Matrix.  This  is  done  in  the  same  way  as 
though  a  greater  bulk  of  gold  was  to  be  added.  Such  inlays 
must  be  retained  by  one  or  more  pins  soldered  to  the  cavity 
side  as  previously  described. 

The  matrix  is  burnished  to  perfect  fit  and  the  outline  defi- 
nitely established.  The  matrix  should  be  trimmed  to  within 
about  one-fourth  millimeter  of  the  cavity  outline  and  re- 
burnished  and  carefully  removed. 

The  matrix  is  then  given  a  coat  of  whiting  on  all  that  por- 
tion which  is  to  contact  with  the  tooth  to  prevent  the  solder 
from  flowing  on  that  surface. 

Sweating  the  Contour.  The  gold  matrix  should  be  then 
laid  upon  the  soldering  block  and  with  a  brush  flame  from  the 
blow  pipe  proceed  to  fuse  22K  plate  or  23K  solder  to  the 
thickness  desired  in  the  various  locations  on  the  matrix. 
When  a  sufficient  amount  has  been  fused  in  any  portion,  that 
part  of  the  surface  should  receive  a  coat  of  whiting. 

Gold  can  then  be  fused  to  still  exposed  surface  without  its 
spreading  to  portions  not  wanted.  By  this  means  it  is  pos- 
sible to  build  up  a  given  portion  of  the  inlay,  even  to  the 
adding  of  cusps  to  occlusal  surfaces. 

Method  of  Using  Sponge  Gold  as  a  model.  Take  the  sponge 
gold  as  bought  on  the  market  for  making  a  cohesive  gold 
filling  and  saturate  it  with  any  casting  wax  on  the  market. 
This  is  best  accomplished  by  dipping  a  sufficient  amount  of 
the  heated  gold,  while  held  in  the  pliers,  into  the  molten  wax, 
and  immediately  remove  to  a  clean  surface  to  cool.  Remove 
any  excess  wax. 

Making  the  Model.  When  this  method  is  used  any  under- 
cuts in  the  cavity  should  be  filled  with  cement.  A  portion 
of  the  saturated  gold  large  enough  to  a  little  more  than  fill 
the  cavity  is  grasped  between  the  pliers  and  slightly  warmed 
and  carried  to  the  cavity  and  crowded  to  position  and  con- 
toured in  much  the  same  way  as  amalgam  is  manipulated.     A 


202  ESSENTIALS  OF  OPERATIVE  DENTISTRY 

matrix  should  be  used  in  class  two  cavities,  but  not  sifficiently 
high  to  prevent  occluding  the  teeth.  When  the  model  has 
been  contoured  to  the  desired  form  the  whole  is  removed  the 
same  as  described  for  removing  a  model  composed  of  wax 
alone. 

Investing,  A  sprue  of  wax  is  attached  to  the  usual  place 
as  though  the  casting  method  was  to  be  used.  The  model  is 
then  submerged  in  much  the  same  way  as  a  tooth  is  invested 
to  have  a  backing  flowed  but  sufificiently  deep  upon  the  wax 
sprue  former  to  leave  upon  its  removal  a  sufficient  receptacle 
for  the  gold  solder  to  be  fused. 

Saturating  the  Model,  Heat  may  be  applied  to  the  invested 
model  as  soon  as  the  investment  has  set,  and  the  wax  gradu- 
ally burned  out  leaving  a  framework  of  pure  gold  filling  the 
mold.  Then  scraps  of  22K  gold  plate  are  placed  in  the  hole 
left  by  the  sprue  former  and  all  is  heated  to  the  point  of  fus- 
ing the  22K  gold  which  will  disappear  through  the  opening 
and  completely  saturate  the  pure  gold  within  the  mold.  The 
inlay  may  be  immediately  chilled  and  finished.  This  method 
has  to  recommend  it  speed  of  manipulation  and  is  indicated 
in  large  contour  restorations,  where  it  is  desired  to  use  a  solid 
inlay. 

Finishing  the  Inlay,  With  any  of  the  processes  of  making 
an  inlay  there  is  liable  to  be  some  imperfections  which  will 
be  seen  upon  removing  from  the  investment.  If  these  are 
on  the  cavity  side  of  the  inlay  and  are  of  any  considerable 
size  it  will  probably  be  necessary  to  make  a  new  model.  If 
they  are  only  slight  and  are  in  the  form  of  little  pedunculated 
masses  they  can  generally  be  removed  without  injury  to  the 
filling.  If  the  contour  shows  that  the  mold  did  not  entirely 
fill  the  necessary  amount  to  complete  contour,  and  the  margin 
is  not  involved  it  may  be  sweat  on  using  a  gold  of  lower 
fusing  point  than  that  of  the  inlay.  Another  method  is  to 
make  a  gold  amalgam  and  build  to  the  desired  contour.  Then 
subject  the  inlay  to  heat  gradually  raised  to  nearly  red  heat 
when  the  mercury  will  be  volatilized  leaving  the  pure  gold 
fused  to  the  position  desired.     This  gold  amalgam  is  made 


MAKING  AND  SETTING  OF  GOLD  INLAY  203 

by  adding  mercury  to  cohesive  gold  foil,  pellets  or  fiber  which 
has  been  annealed,  mixing  thoroughly  in  the  palm  of  the 
hand  and  applying  it  immediately  to  place.  All  exposed  sur- 
faces of  gold  inlays  should  receive  a  high  polish  before  setting, 
omitting  a  line  about  one-fourth  of  a  millimeter  next  to  the 
entire  margin. 

Setting  the  Inlay.  The  inlay  should  be  washed  with  water 
and  dried.  Then  dipped  in  chloroform  to  remove  any  oil 
that  may  have  adhered  from  the  hands.  The  cavity  should 
be  freed  from  all  foreign  substance,  given  complete  retentive 
form  bathed  with  alcohol  and  chloroform  in  the  order  named 
and  the  surface  of  the  cavity  entirely  covered  with  cement. 

The  inlay  is  given  a  coat  of  cement  on  its  cavity  side  from 
the  same  mix  and  gently  but  firmly  moved  to  position  usmg 
hand  pressure  assisted  by  light  blows  from  the  mallet.  The 
inlay  should  be  subjected  to  pressure  directed  toward  the 
seat  of  the  cavity  for  some  minutes  which  will  in  a  measure 
overcome  the  tendency  toward  displacement  caused  by  the 
expansion  of  the  cement.  An  inlay  may  be  finished  at  its 
margins  within  30  minutes  from  setting,  but  it  is  better  if 
this  step  is  attended  to  at  a  subsequent  time. 


204  ESSENTIALS  OF  OPERATIVE  DENTISTRY 


CHAPTER  XXXIII. 

Manipulation  of    Cohesive  Gold  in  the    Making  of  a  Filling. 

Physical  Properties.  The  physical  properties  most  desired 
in  a  filling  are  found  in  cohesive  gold  to  a  greater  degree  than 
in  any  other  filling  material,  which  places  it  at  the  head  of  the 
list  as  a  means  of  restoring  lost  contour  and  preventing  re- 
currence of  decay.  It  is  not  affected  by  the  fluids  of  the 
mouth ;  it  may  be  very  perfectly  adapted  to  the  walls  of  the 
cavity;  the  shrinkage  and  expansion  range  in  varying  tem- 
perature is  very  slight;  the  cavity  can  be  filled  immediately 
upon  freshly  cut  surfaces  before  they  have  been  contaminated, 
an  advantage  over  the  fused  inlay,  and  when  sufficiently  con- 
densed, possesses  a  greater  specific  gravity,  hence  density,  than 
a  fused  inlay,  of  pure  gold.  Hammered  gold  will  flow  under 
sufficient  stress  and  always  in  proportion  to  the  load,  when  it 
ceases  to  flow,  unless  the  load  is  increased,  a  marked  distinc- 
tion between  it  and  amalgam.  This  quality  of  gold  makes  it 
possible  to  build  a  filling  which  will  at  once  sustain  the  force 
of  mastication  provided  it  has  received  sufficient  aggregate 
weight  during  the  process  of  introduction.  This  physical 
property  of  gold  is  also  of  service  in  the  fact  that  it  does  not 
farther  compress  when  firmly  wedged  between  the  walls  of 
living  dentine  which  are  elastic  and  retain  a  certain  amount 
of  residual  elasticity  which  permanently  grasps  the  unyield- 
ing gold.  The  expansion  and  contraction  of  gold  under  the 
varying  oral  temperatures  is  fully  compensated  for  by  this 
residual  elasticity  of  the  dentine  so  that  the  closely  adapted  co- 
hesive gold  filling  is  at  all  times  in  perfect  adaptation. 

The  Objectionable  Qualities  of  Gold.  Gold  is  a  good  con- 
ductor of  thermal  changes,  hence  endangers  the  health  of 
vital  pulps.     The  color  is  an  objection  in  anterior  positions. 


MANIPULATION  OF  COHESIVE  GOLD  205 

and   the  process   of  building  a   filling  is   comparatively   slow 
and  taxing  on  patient  and  operator. 

Welding  of  Gold.  Gold  welds  cold,  when  properly  pre- 
pared, is  absolutely  pure,  and  the  contacting  surfaces  are 
clean.  Any  alloy  in  its  substance  (excepting  platinum)  or  for- 
eign substance  upon  its  surface  totally  destroys  this  quality, 
till  such  substances  are  removed,  when  the  property  of  weld- 
ing cold  again  returns. 

If  the  Surface  of  Foil  Becomes  contaminated  with  a  non- 
evaporable  substance  the  injury  is  permanent. 

To  Protect  the  Surface  of  Gold.  Place  in  the  drawer  where 
the  gold  is  kept  a  small  pledget  of  cotton  or  spunk  saturated 
with   ammonia. 

Ammonium  salts  will  form  on  the  surface  of  the  gold  which 
is  easily  volatilized  by  heat,  leaving  the  gold  clean.  Before 
annealing,  such  gold  will  be  found  thoroughly  non-cohesive. 
This  method  of  treating  the  gold  to  the  fumes  of  ammonia 
will  obviate  the  necessity  of  keeping  more  than  one  kind  of 
gold  on  hand,  as  all  will  be  non-cohesive  till  annealed  and  can 
be  used  in  either  form. 

Annealing  Gold  is  for  the  sole  purpose  of  cleaning  the  sur- 
face of  the  gold,  volatilizing  any  film  that  may  have  collected. 

The  Degree  of  Heat,  is  about  1100  degrees  Fr.  or  just  below 
red  heat. 

In  the  daylight  this  color  is  not  apparent,  but  on  a  dark  day 
the  dull  red  color  should  show.  The  gold  is  not  materially 
injured  if  carried  to  the  full  red  of  1200  or  1300  degrees,  but 
in  no  case  should  the  melting  point  be  reached,  as  it  destroys 
the  possibility  of  adaptation  to  the  walls  of  the  cavity,  or 
the  surface  of  the  gold  already  in  place. 

Methods  of  Annealing.  The  electric  anncaler  is  by  far  the 
most  satisfactory  means  as  it  is  possible  to  always  obtain 
the  same  degree  of  heat  for  a  continued  period. 

The  Next  Best  means  is  to  place  the  gold  on  a  tray  above 
a  flame,  thus  separating  the  flame  from  the  gold,  preventiu'- 


206  ESSENTIALS  OF  OPERATIVE  DENTISTRY 

contamination   of   the   gold   with    carbon,    and   various    gases 
which  are  frequently  met  with  in  combustion. 

Gold  Should  Not  Be  Annealed  by  passing  the  gold  through 
the  open  flame  of  either  gas  or  alcohol,  holding  the  gold  either 
on  a  plugger  point  or  the  foil  carriers.  This  is  quite  a  com- 
mon practice  which  should  be  discontinued.  In  the  first 
place  contacting  the  gold  with  the  open  flame  frequently  con- 
taminates its  surface  to  the  injury  of  its  welding  properties. 

Also  that  portion  of  the  gold  next  to  the  carrier  is  not  suf- 
ficiently heated  and  remains  non-cohesive,  a  fact  which  is 
shown  by  the  subsequent  pitting  of  the  surface  of  the  filling 
during  service  by  the  flecking  off  of  these  non-cohesive  par- 
ticles. 

Secific  Gravity.  The  specific  gravity  of  the  cast  gold  inlay 
is  about  19. 

It  is  possible  to  condense  a  cohesive  gold  filling  when  con- 
fined between  the  walls  of  elastic  dentine  so  as  to  obtain  a 
slightly  greater  specific  gravity  than  the  cast  inlay.  How- 
ever this  degree  of  solidity  is  not  possible  of  attainment  un- 
less the  gold  is  confined  and  the  wedging  principle  is  taken 
advantage  of. 

Cohesion  of  Gold.  The  surfaces  of  pure  gold  when  abso- 
lutely clean  readily  cohere.  This  cohesion  is  brought  about 
by  the  friction  of  the  surfaces  of  the  gold  when  in  abso- 
lute adaptation.  The  degree  of  cohesion  is  in  proportion  to 
the  friction.  The  friction  is  in  proportion  to  the  load,  the 
extent  of  the  surfaces  in  opposition  and  the  speed  of  the 
travel  of  the  surfaces  one  upon  the  other.  Hence  the  great- 
er the  load,  the  smaller  the  surface,  and  the  more  rapid  the 
movement  of  one  surface  upon  the  other,  the  greater  the  co- 
hesion. Polished  surfaces  of  gold  must  be  brought  into  co- 
adaptation  in  order  to  get  cohesion.  The  smaller  the  sur- 
faces and  the  thinner  the  sheets,  the  less  load  and  speed  will 
be  required. 

The  Serrated  Plugger  Points,  are  used  in  condensing  co- 
hesive gold  for  the  following  reasons :  That  these  polished 
surfaces  may  be  kept  small  and  uniform ;  that  great  pressure 


MANIPULATION  OP  COHESIVE  GOLD  207 

(load)  may  be  easily  exerted  on  the  polished  planes  previously 
left  in  the  surface  of  the  gold  by  the  wedge  shaped  serrations. 
The  mallet  is  applied  to  give  the  additional  factor  in  friction 
(speed)  as  the  fresh  gold  is  moved  over  these  small  polished 
surfaces.  The  above  conditions  are  obtained  w^ith  the  least 
exertion  on  the  part  of  the  operator  and  annoyance  to  the 
patient  by  the  serrated  plugger  point  which  is  made  of  a  col- 
lection of  pyramids  which  act  as  so  many  wedges  and  exert 
great  lateral  force  (load)  upon  the  polished  sides  of  their 
previous  impressions.  That  gold  coheres  to  polished  sur- 
faces can  be  easily  demonstrated  by  taking  any  cohesive  gold 
filling  and  burnishing  its  surface  to  a  glossy  finish.  Pellets 
of  gold  from  the  annealer  will  readily  cohere  and  the  filling 
may  be  continued  to  full  contour  by  applying  a  steel  burnisher 
with  heavv  pressure  drawn  over  the  surface  of  the  fresh  gold. 
This  process  proves  that  burnished  gold  coheres,  but  it  is 
slow  and  laborious  and  objectionable  to  the  patient,  hence 
the  serrated  plugger  point  which  accomplishes  the  same  re- 
sult, the  friction  of  polished  surfaces  of  gold  under  pressure 
causing  their  welding. 

Bridging,  is  the  term  applied  to  that  faulty  manipulation 
which  results  in  air  spaces  within  the  body  of  the  filling,- 
caused  by  the  gold  failing  to  reach  the  bottom  of  the  indenta- 
tions of  the  serrated  plugger  point. 

The  Cause  may  be  insufficient  pressure  being  given  the 
plugger  point,  the  gold  thereby  stopping  short  of  the  bottom 
of  the  serrations,  or  it  may  be  caused  by  too  much  light  mallet- 
irig,  going  over  the  gold  surface  repeatedly  thereby  bending 
down  the  crests  of  the  pyramids  thus  choking  them  to- the 
entrance  of  the  gold.  Again  it  may  be  caused  by  changing 
to  a  plugger  with  a  less  number  of  serrations  to  the  milli- 
meter, or  one  wherein  the  serations  are  not  as  dee])ly  cut,  re- 
sulting in  a  collection  of  pyramids  that  do  not  reach  the  bot- 
tom of  the  indentations  made  by  the  previous  plugger. 

Plugger  Points  Should  Have  the  same  Sized  Serrations. 
Each  operator  should  have  a  set  of  gold  plugger  points  of  the 
same  denomination  as  to  the  cuttings  on  the  working  point 


208  ESSENTIALS  OF  OPERATIVE  DENTISTRY 

to  use  in  the  same  filling.  When  forced  to  change  to  one  of 
diffrent  sized  serrations  the  surface  of  the  filling  should  be 
gone  entirely  over  with  the  new  plugger  to  be  used,  before 
adding  additional  gold.  This  will  create  a  new  set  of  facets 
to  accommodate  the  gold  added  with  the  new  instrument. 

A  little  care  in  this  respect  will  greatly  increase  the  speci- 
fic gravity  of  the  cohesive  gold  filling. 

Rotating  the  Plugger  in  the  Fingers  should  be  avoided. 
The  serrations  are  cut  on  the  square  and  unless  the  point 
is  rotated  one-fourth  of  a  circle  each  time  the  pyramids  will 
ride  the  crests  of  the  indentations,  whereas  if  the  shaft  is  held 
in  one  position  as  described,  the  leverage  produced  by  the 
plane  on  the  surface  of  the  plugger  point  coming  in  contact 
with  the  plane  on  the  surface  of  the  filling,  will  twist  the 
plugger  point  to  position  with  each  blow  of  the  mallet.  All 
this  will  prove  plain  to  the  vision  if  the  field  of  operation  is 
viewed  under  a  high  power  lens  while  operating-  with  a  ser- 
rated plugger  on  the  surface  of  gold  in  a  technic  block. 

The  Size  of  the  Plugger  Point.  This  depends  entirely 
upon  the  force  with  which  it  can  be  used.  It  would  seem 
from  all  the  facts  at  hand  that  a  point  with  the  surface  of  ' 
square  millimeter  should  be  regarded  as  the  maximum.  The 
force  required  to  properly  condense  gold  with  a  point  of 
greater  surface,  is  either  not  permissible  in  many  cases  or 
many  times  not  possible  with  the  operator.  A  point  of  one 
millimeter  should  receive  a  load  of  15  lbs.  pressure  at  each 
contacting  of  the  point. 

At  the  same  time  points  of  less  than  one-half  millimeter 
will  chop  the  surface  by  disturbing  the  gold  close  to  the  point 
with  each  impact;  hence  we  are  limited  to  a  narrow  range  as 
to  size  of  points. 

Preparation  of  the  Foil.     The  gold  foil  may  be  used  from 
the  book  as  it  comes  from  the  dealer,  and  shaped  as  drs^ 
by  the  operator,  or  it  may  be  purchased  as  cylinders,  squares, 
ropes  and  various  other  forms. 

The  shaping  should  be  done  without  bringing  the  gold  in 
direct  contact  with  the  fingers,  and  all  manipulation  and  cut- 
ting should  be  done  previous  to  annealing. 


MANIPULATION  OF  COHESIVE  GOLD  209 

The  Application  of  the  Foil.  In  whichever  form  the  foil 
has  been  shaped,  it  should  be  so  placed  upon  the  surface  of 
condensed  gold  that  the  leaves  lay  flat.  If  the  pellets  are 
placed  so  that  the  leaves  of  gold  are  crumpled  in  packing  to 
place  the  specific  gravity  will  not  be  as  great  in  the  finished 
filling.     Neither  will  the  cohesion  be  as  perfect. 

Sheet  gold  has  left  in  it  a  certain  amount  of  spring  even 
after  annealing  that  has  to  be  overcome  if  folded.  The  less 
handling  of  the  sheets  in  folds  when  packing  the  better  the 
result.  The  gold  should  be  grasped  by  the  carriers  with  as 
small  a  bite  as  possible  to  prevent  precondensation  and  carried 
to  the  position  desired  and  condensed,  with  no  attempt  to 
shift  its  position  by  pushing  or  poking  it  around  over  the  sur- 
face. 

If  the  pellet  is  placed  near  a  wall,  it  should  be  placed  so  that 
it  lies  fully  against  that  wall  that  it  may  be  crowded  for  room 
when  condensed.  Short  of  this  will  hinder  the  wedging  prin- 
ciple in  packing.  If  the  new  pellet  is  to  come  out  to  contour 
it  should  reach  slightly  beyond  contour  and  be  burnished  back 
to  contour  with  a  flat  faced  steel  burnisher. 

The  Forces  used  in  Condensing  Cohesive  Gold.  There  are 
two  principal  forces  used  in  condensing  cohesive  gold ;  hand 
pressure  and  blows  from  the  mallet.  These  may  be  either 
alone  or  one  following  the  other  or  in  combination,  the  last 
named  being  the  most  popular,  the  least  taxing  on  patient 
and  operator  and  produces  as  great  specific  gravity  in  less 
time.  However  the  best  results  are  obtained  by  using  each 
method  at  given  times  in  the  process  of  building  most  fillings. 

To  Illustrate.  Hand  pressure  alone  should  be  used  in  the  fill- 
ing of  convenience  angles.  Also  when  on  account  of  position 
the  force  must  be  applied  at  nearly  a  right  angle  to  the  wall 
against  which  the  gold  is  being  condensed,  as  in  starting  a  fill- 
ing and  when  covering  the  seat  of  the  caxily  with  the  first  one- 
half  millimeter  of  gold. 

With  the  plugger  point  pointing  directly  at  a  dentinal  wall 
with  a  thin  layer  of  gold  between,  the  elasticity  of  the  dentine 
causes  the  gold  to  rebound  when  struck  a  blow  with  the  mal- 

(8) 


210  ESSENTIALS  OF  OPERATIVE  DENTISTRY 

let.  In  such  positions  the  closest  adaptation  is  secured  by 
hand  pressure  alone  and  should  be  applied  with  a  rocking- 
motion  secured  by  swaying  the  outer  end  of  the  plugger  from 
side  to  side  for  a  distance  of — say  one  inch—  at  each  chang-e 
of  position. 

Hand  Pressure  Alone  is  also  of  most  service  when  packing 
gold  against  thin  walls.  Again  in  cases  where  the  conden- 
sing force  should  be  applied  at  an  angle  to  the  long  axis  of 
the  shaft  of  the  plugger  point  as  sometimes  met  with  in  distal 
cavities  in  posterior  teeth  with  a  distal  inclination.  Hand 
pressure  alone  is  required  when  it  becomes  necessary  to  use 
force  at  an  angle  which  would  tend  to  unseat  the  filling. 

A  fining  should  never  receive  a  blow  through  the  plug- 
ging instrument  when  that  instrument  does  not  point  quite 
directly  toward  one  of  the  inner  walls  of  the  cavity  preferably 
the  seat. 

Mallet  Force  Alone  is  of  service  in  adding  the  last  portions 
of  gold  to  an  occlusal  surface  when  adding  thin  layers  of  gold 
at  each  time,  resulting  in  a  very  hard  surface. 

A  Good  Rule  is  to  increase  the  (load)  hand  pressure  both 
in  frequency  and  weight  as  you  increase  the  thickness  of  the 
pellets  applied,  and  as  the  angle  which  the  gold  is  driven  to 
a  dentinal  wall  approaches  a  right  angle. 

The  Different  Plans  of  Mallet  Force. 

Hand  Mallet.  By  far  the  best  mallet  force  is  the  hand 
mallet  driven  by  an  experienced  assistant.  By  this  method 
the  operator  is  able  to  vary  the  amount  of  hand  pressure 
(load)  and  its  relation  to  the  mallet  force  (velocity)  at  will 
all  through  the  filling,  as  well  as  at  different  points  in  the 
condensing  of  a  single  pellet  of  gold,  a  point  of  no  small  con- 
sequence. 

The  Automatic  Mallet.  It  has  been  attempted  to  imitate 
this  combination  method  in  the  automatic  plugger,  and  is 
today  the  best  substitute  for  the  hand  pressure  and  assistant 
mallet  method,  but  it  must  be  regarded  as  a  substitute  only 
and  supphes  a  need  in  the  absence  of  better  facilities. 

Power  Mallet.     Power  mallets  either  electric  or  mechani- 


MANIPULATION  OF  COHESIVE  GOLD  211 

cally  driven  by  the  engine  are  of  service  in  that  part  of  each 
filling  where  mallet  force  alone  is  indicated  as  previously 
described.  But  this  is  such  a  small  proportion  of  each  filling 
that  most  operators  do  not  care  to  bother  with  them  and  few 
have  them  at  hand. 


CHAPTER  XXXIV. 

Manipulation  of  Cohesive  Gold  in  the  Making  of  Fillings  by 

Classes. 

Class  I.  Pit  and  Fissure.  This  class  of  cavities  is  the 
easiest  of  all  in  that  they  are  surrounded  by  solid  walls  of 
dentine  with  generally  only  one  wall  missing,  which  is  the 
means  of  access  to  the  cavity. 

Starting  the  Filling,  In  the  case  of  a  small  pit  cavity  it  is 
generally  well  to  start  with  a  piece  of  gold  that  is  sufficiently 
large  to  more  than  cover  the  internal  wall  and  condense  the 
greater  portion  with  a  rather  large  plugger  point  using  hand 
pressure  alone  on  this  piece.  With  occlusal  cavities  the  inner 
wall  is  the  pulpal  wall.  When  the  cavity  is  in  an  axial  surface 
it  is  the  axial  wall. 

A  second  pellet  of  gold  may  be  added  and  condensed  in  the 
same  way.  The  mallet  force  should  now  be  used  on  a  smaller 
plugger  point  going  entirely  around  the  cavity  close  to  the 
walls  holding  the  shaft  of  the  plugger  at  an  angle  of  about 
12  degrees  centigrade  to  the  wall  against  which  the  con- 
densing is  being  done. 

In  Occlusal  Cavities  the  condensing  should  be  in  the  cen- 
tral portion  first ;  then  next  to  the  distal  wall ;  then  along  the 
buccal  and  lingual  walls  and  lastly  the  mesial  wall.  This  plan 
of  procedure  pertains  to  each  separate  layer  of  gold  as  it  is 
applied   when    treating  simple   occlusal   pits. 

In  Buccal  Cavities  the  order  of  stepping  is  1st,,  center  of 
filling,  ynd,  gingival,  .'5rd  distal,  4th  mesial  and  fjth  occlusal. 

When  the  Cavity  Has  a  Long  Irregular  Outline  caused  by 
the  ffjllowing  out  of  one  or  more  rather  long  fissures  the  plan 


212  ESSENTIALS  OF  OPERATIVE  DENTISTRY 

is  the  same,  excepting  that  the  most  distant  arm  of  the  cavity- 
is  filled  first,  allowing  the  gold  to  gradually  build  toward  the 
operator's  viewpoint,  covering  the  base  wall,  portion  by  por- 
tion, with  the  plugger  point  always  at  the  given  angle  to  this 
base  wall,  which  permits  of  the  use  of  mallet  force  after  the 
first  pieces  of  gold  have  been  securely  anchored  along  the 
disto-pulpal   line    angle. 

Class   2.     Proximal    Cavities    in    Bicuspids    and    Molars. 

Beginning  the  Filling.  There  are  three  distinct  methods 
of  starting  a  filling  of  cohesive  gold  in  this  class  of  cavities. 
It  is  well  if  both  gingival  point  angles  are  sharpened  to  a  con- 
venience angle.  It  will  not  suffice  to  have  these  made  into 
the  form  of  a  round  hole  or  slot,  but  they  should  be  shaped  up 
to  the  distinct  wedge  shape.  This  shape  will  cause  the  con- 
densed gold  to  crowd  the  elastic  dentine  on  all  sides  as  it 
is  driven  to  place  and  insure  the  stability  of  the  first  piece  of 
gold.  If  this  small  convenience  angle  is  not  sharp  at  its 
deepest  point,  but  has  a  flat  wall  or  seat,  the  mallet  force  is 
precluded  as  that  flat  wall  will  not  permit  its  use,  the  elas- 
ticity of  which  will  cause  the  gold  to  rebound  when  struck 
a  blow,  whereas  when  this  point  is  sharp  and  the  approach- 
ing sides  leave  a  wedge-shaped  opening  the  gold  is  firmly 
grasped  when  driven  to  position.  Attention  to  this  small 
detail  will  make  easy  starting  of  such  fillings. 

As  to  the  Three  Plans  of  Starting  Class  II 

The  First  Plan,  and  probably  the  most  popular,  is  to  fill  one 
convenience  angle,  the  one  the  farthest  from  the  viewpoint 
of  the  operator  and  while  supporting  this  in  position  with  a 
suitable  instrument  build  along  the  gingio-axial  line  angle 
to  the  other  point  angle. 

A  Second  Plan  is  to  fill  each  point  angle  separately  and  join 
the  two  with  a  third  piece  of  gold  laid  along  the  gingio-axial 
line  angle. 

A  Third  Plan  is  to  start  with  a  quantity  of  gold  sufficient  to 
fill  both  point  angles  and  cover  the  connecting  line  angle  as 
well  as  a  considerable  portion  of  the  gingival  wall  next  to  the 
axial.     This  last  plan  is  one  used  by  some  experienced  opera- 


MANIPULATION  OF  COHESIVE  GOLD  213 

tors  and   is  well  to  attempt  when   working  for  speed.     The 
beginner  will  do  well  with  the  first  plan. 

The  Order  of  Stepping  the  Plugger  in  Class  II.  With 
each  pellet  of  gold  added,  the  wedging  principle  is  made  most 
effective  by  the  following  order  of  stepping.  Center  of  fill- 
ing first;  contour  second;  ascending  line  angles  third;  sur- 
rounding walls  fourth  and  against  ascending  cavo-surface 
angles  fifth,  keeping  the  long  axis  of  the  plugger  shaft  at 
about  a  twelve  degree  centigrade  angle  to  the  axial,  buccal 
and  ingual  walls. 

When  the  Gold  Extends  Beyond  Contour,  it  should  be  bur- 
nished back  to  correct  position  and  the  plugger  again  stepped 
along  the  contour,  holding  the  plugger  close  to  a  line  of  the 
long  axis  of  the  tooth,  instead  of  striking  the  gold  at  nearly  a 
right  angle  to  this  line,  a  practice  so  common  with  operators, 
as  it  has  a  tendency  to  unseat  the  filling  and  separate  the  lay- 
ers of  the  filling  already  condensed. 

The  Progress  of  the  Filling  should  be  largely  at  right  angles 
to  the  plane  of  the  gingival  wall  and  kept  in  this  plane  to  near 
the  completion  of  the  filling,  having  a  strict  care  as  to  com- 
plete contour  in  the  proximal,  as  the  filling  advances. 

Covering  the  Pulpal  Wall.  There  are  two  plans  of  cover- 
ing the  step  portion  in  class  II.  The  first  and  most  common 
is  to  build  the  cavity  portion  to  a  level  of  the  pulpal  wall  and 
gradually  cover  the  pulpal  wall  by  allowing  each  pellet  of 
gold  to  extend  a  little  farther  than  the  previous  one  out  over 
the  pulpal  wall  till  the  pulpal  point  angles  have  been  reached. 

The  Second  Plan  is  to  start  an  independent  body  of  gold  in 
the  pulpal  point  angles  in  one  of  the  three  ways  outlined  in 
starting  the  cavity  portion  on  the  gingival  wall  and  finally 
uniting  the  two  portions  of  the  filling.  Whichever  plan  is 
used  nothing  should  be  done  in  the  way  of  covering  the  pulpal 
wall  till  the  gold  in  the  cavity  portion  has  reached  a  level 
with  the  axio-pulpal  line  angle. 

The  Contact  Point.  The  building  of  contact  point  should 
receive  special  attention  wlicn  the  proper  height  of  the  filling 
lias    been    reached.     The    gold     should     be     thoroughly     con- 


214 


ESSENTIALS  OF  OPERATIVE  DENTISTRY 


densed  against  the  proximating  tooth  much  in  the  same  man- 
ner as  it  is  wedged  against  the  walls,  and  should  receive  extra 
malleting  to  insure  extreme  hardness. 

Position  of  Contact  Point.  When  the  proximating  tooth 
is  intact,  the  contact  point  should  be  in  about  the  same  po- 
sition as  it  was  previous  to  decay,  and  should  be  a  contacting 
point  and  not  surface  or  a  line  of  contact.  This  should  round 
away  from  this  point  in  much  the  same  manner  as  do  the  sur- 
faces of  two  marbles  when  contacted  and  has  come  to  be 
spoken  of  as  the  "marble  contact."     (Figure  43.) 


Figure  42.     Shows   the   "marble   contact." 

Moving  Contact  Flush  to  Occlusal.  The  contact  point 
should  be  moved  to  the  occlusal  when  both  proximating  sur- 
faces are  to  be  restored,  one  a  mesial  and  the  other  a  distal 
filling  in  the  teeth  making  up  the  proximal  space  being  con- 
sidered. This  will  result  in  a  contact  point  from  which  the 
surfaces  round  away  in  all  directions  except  toward  the  oc- 
clusal and  is  known  as  the  "half  marble  contact"  and  is  ad- 
vised for  the  above  condition  only.  (Figure  43  in  contrast 
with  that  of  42.     The  full  marble  contact).     In  this  connection 


Figure  43.     Showing  the   half  marble   contact  advised   in  double 
proximal  fillings. 


MANIPULATION  OF  COHESIVE  GOLD  215 

attention  is  called  to  the  immunity  to  decay  of  proximating 
surfaces  where  the  ''half  marble  contact"  has  been  produced  by 
occlusal  wear.  Many  instance  are  seen  where  caries  al- 
ready started  in  such  spaces  have  ceased  to  progress  because 
of  the  cleanliness  of  such  surfaces,  due  to  the  lack  of  the 
egress  of  food  substances. 

The  Last  Portions  of  Gold.  After  leaving  contact  point 
the  last  portions  of  gold  are  added  to  restore  normal  contour 
or  as  near  that  condition  as  occlusion  and  articulation  will 
permit  giving  special  care  to  complete  covering  of  the  cavo- 
surface  angle  at  all  points. 

Filling  Class  II  With  Matrix  in  Position.  This  may  be 
done,  and  is  advised  by  some  operators,  who  advance  the 
theory  of  additional  condensation  due  to  the  presence  of  the 
substitute  for  the  missing  wall. 

When  the  matrix  is  used  it  should  not  be  adjusted  till  the 
gingival  cavo-surface  angle  is  covered.  It  should  be  thor- 
oughly wedged  at  the  gingival.  The  matrix  should  be  re- 
moved just  before  the  gold  has  been  built  to  the  height  of 
contact  point. 

The  Use  of  the  Separator  in  Class  II.  In  cases  where  pre- 
liminar}^  separation  has  not  been  made,  a  mechanical  separa- 
tor should  be  adjusted  and  tightened  at  short  intervals  to  the 
full  extent  of  safety.  This  will  permit  of  better  and  more 
thorough  finishing  of  contact  point  as  the  sHght  space  result- 
ing will  be  taken  up,  upon  the  removal  of  the  separator. 

Class  III.  Proximal  in  the  six  anterior  not  involving  the 
angle. 

Starting  the  Gold,  in  cavities  class  three,  is  the  same  in 
large  or  small  cavities.  The  gold  is  first  condensed  into 
the  wedge-shaped  convenience  angle  farthest  from  the  view 
point  of  the  operator  which  is  the  gingio-axio-lingual  angle. 
The  gold  is  kept  in  this  triangular  form  by  covering  equally 
rapid  the  three  walls  forming  the  angle  ;  the  gingival,  axial 
and  lingual  walls,  keeping  the  shaft  of  the  plugger  pointing 
all  the  time  at  the  point  angle  primarily  covered. 

When  the  gold  has  been  built  out  along  the  gingio-lingual 


216  ESSENTIALS  OP  OPERATIVE  DENTISTRY 

line  angle  to  the  cavo-surface  angle  great  care  must  be  taken 
at  this  stage  of  the  filling  that  the  lingo-gingival  angle  is 
covered  and  the  gold  built  to  full  contour,  as  this  is  the  only- 
time  it  can  be  correctly  done  with  the  force  directed  in  the 
right  direction.  As  the  gold  reaches  the  height  of  the  gingio- 
axio-labial  angle  this  should  be  thoroughly  filled  and  the  fill- 
ing continued,  maintaining  the  same  level  of  the  gold,  restor- 
ing full  contour  past  contact  point  which  should  be  well  con- 
densed and  burnished. 

Filling  Incisal  Angle.  Shortly  after  passing  contact  point 
the  gold  should  be  advanced  along  the  axio-  lingual  angle 
to  the  incisal  angle  which  should  then  be  filled  using  hand 
pressure  alone  as  the  direction  of  the  force  will  not  permit  of 
the  use  of  the  mallet.  The  filling  should  then  be  completed 
with  the  plugger  point  still  directed  toward  the  angle  where 
gold  was  first  condensed,  the  last  portions  of  gold  being  added 
to  the  labial  portion  of  the  filling  at  the  incisal  extremity. 

With  Lingual  Approach  in  class  three  the  whole  plan  is 
reversed.  The  gold  is  first  built  into  the  gingio-axio-labial 
angle.  The  plugger  point  is  maintained  in  a  position  point- 
ing at  this  angle  as  the  filling  progresses,  till  the  last  additions 
of  gold  are  to  the  lingual  surface  at  the  incisal  extremity,  all 
the  while  the  operator  is  working  to  the  image  reflected  in 
the  mouth  mirror. 


Figure  44.     Class  3  lingual  approach. 

The  Lingual  Approach  is  Advised  in  cases  where  ample 
preliminary  separation  is  secured  or  when  the  lingual  wall 
is  wanting  and  the  axial  wall  meets  the  lingual  cavo-surface 


MANIPULATION  OF  COHESIVE  GOLD  217 

angle.  (Outline  is  shown  in  figure  44.)  That  said  about  the 
use  of  the  mechanical  mallet  in  class  II  applies  to  class  III 
with  equal  force. 

Class  IV  Proximal  Cavities  in  Incisors  and  Cuspids  In- 
volving the  Angle.  The  removal  of  the  incisal  angle  permits 
of  the  plugger  point  being  used  in  an  ideal  angle  to  the  walls 
and  allows  the  force  being  applied  more  nearly  from  the  di- 
rection that  the  subsequent  force  of  service  is  received. 

Starting  the  Filling.  These  fillings  are  started  as  has  just 
been  described  with  class  III.  However  the  gingival  wall 
should  be  most  rapidly  covered  and  the  plan  of  building  sim- 
ilar to  that  described  for  class  II  keeping  the  surface  of  the 
gold  on  the  same  plane  as  the  gingival  wall,  restoring  lost 
contour  as  the  filling  advances,  and  maintaining  the  plugger 
point  at  about  12  degrees  centigrade  to  the  surrounding  walls. 

The  Final  Portions  of  Gold  should  be  condensed  on  the  ex- 
treme incisal  angle  with  the  shaft  of  the  plugger  point  still 
maintained  at  an  angle  of  12  degrees  to  the  plane  of  the  axial 
wall. 

The  Layers  of  Gold  in  class  IV  should  receive  some  at- 
tention and  Avhat  is  said  in  this  connection  is  true  of  all  con- 
tour restorations  subject  to  great  stress.  Not  a  little  trouble 
has  been  experienced  in  the  breaking  of  such  fillings  through 
given  lines  of  fracture. 

These  should  be  noticed  and  the  layers  of  gold  leaf  so  placed 
as  to  cross  these  lines.  The  tensile  strength  of  the  sheets 
of  gold  is  greater  than  the  usual  cohesion  obtained  giving  a 
filling  more  strength  across  the  laminations  than  parallel  with 
them. 

Class  V.  Cavities  in  the  gingival  third  need  no  special 
mention  as  they  are  built  under  the  rules  already  outlined  in 
class  I. 

The  gold  is  usually  started  in  the  disto-axio-ginglval  angle 
and  carried  along  the  gingio-axial  line  angle  to  the  other  gin- 
gival point  angle.  The  gingival  wall  will  be  the  first  wall  to 
be  completely  covered.  The  mallet  force  should  at  no  time 
be  directed  at  a  right  angle  to  any  wall. 


218  ESSENTIALS  OF  OPERATIVE  DENTISTRY 

Class  VI  Abraded  Surfaces.  These  cavities  are  built  the 
same  as  large  flat  cavities  in  the  same  surface,  the  principles 
of  which  have  been  given. 


CHAPTER    XXXV. 

Finishing  Gold  Fillings. 

Secondary  Consideration.  When  a  gold  hilling  has  been 
built  to  its  full  size,  the  entire  surface  should  be  gone  over 
with  a  plugger  point  of  moderate  size.  The  point  should  be 
stepped  so  as  to  cover  every  accessible  part  of  the  hilling. 

A  light  mallet  with  a  hard  surface  should  be  used.  A  two 
ounce  steel  faced  mallet  is  preferred. 

Burnishing.  All  accessible  parts  of  the  surface  should  then 
be  thoroughly  burnished  with  a  steel  burnisher.  The  egg 
shaped  burnisher  is  of  most  universal  use  as  it  will  reach  most 
positions. 

If  the  filling  is  a  proximal  filling,  class  2,  3,  or  4,  a  thin  steel 
hand  matrix  should  be  forced  between  the  filling  and  the  prox- 
imating  tooth  to  burnish  the  contact  point  and  to  better  con- 
dense and  harden  the  filling  at  this  place.  This  is  done  by 
swinging  the  handle  back  and  forth  describing  the  part  of  a 
circle,  till  there  is  more  or  less  freedom  of  movement  of  the 
burnisher. 

Following  this  secondary  condensation  the  process  of 
smoothing  the  surface  with  abradents  begins.  The  first  ef- 
forts should  be  to  find  cavity  outline.  Second,  correct  con- 
tour in  localities  where  an  excess  has  been  built  and  third, 
polish  contact  point. 

This  is  best  accomplished  by  the  use  of  small  carborundum 
stones  on  occlusal  surfaces,  disks  on  buccal,  lingual  and  lab^' 
contours,  and  narrow  coarse  strips  in  the  proximal  gingivally 
from  contact  point  assisted  by  the  use  of  file  cut  burnishers. 

Attention  should  first  be  given  to  all  parts  of  the  filling  ex- 
cept contact  point  which,  in  all  proximal  fillings  should  be 
the  last  place  to  receive  finish. 


FINISHING  GOLD  FILLINGS  219 

The  use  of  the  saw  in  the  proximal  space  in  the  finishing  of 
the  fining-  can  not  be  too  strongly  condemned.  In  the  first  place 
no  cutting  instrument  or  coarse  abradent  as  strips  or  disks 
should  be  made  to  pass  contact  point  except  where  there  has 
been  ample  preliminary  separation  and  the  return  of  the  teeth 
to  position  is  relied  upon  to  close  the  resultant  space.  Again 
there  is  no  excuse  for  building  an  excess  of  contour  sufficient 
to  engage  the  bite  of  a  saw  blade. 

The  excess  at  the  gingival  should  be  slight  and  it  with  the 
excess  fullness  in  the  embrasures  should  be  filed  away  with 
the  files,  or  whittled  off  with  the  finishing  knife,  the  edge  of 
which  should  be  keen.  The  files  should  be  carried  through  the 
embrasure  as  far  toward  the  center  of  the  filling  as  possible 
and  drawn  directly  outward  and  over  the  edge  of  the  filling  out 
to  the  external  enamel  surface. 

The  finishing  knife  should  be  engaged  into  the  substance  of 
the  gold  and  drawn  from  the  gum  and  at  the  same  time  out- 
ward, taking  off  only  a  small  portion  of  gold  at  each  cut. 

Coarse  abradents  as  carborundum  stones  and  coarse  disks 
and  strips  should  be  abandoned  as  soon  as  a  near  approach  to 
the  cavo-surface  angle  is  reached,  and  the  files,  plug  finishing 
burs,  and  knife  edged  instruments  resorted  to,  to  bring  into 
view  the  exact  cavity  outline,  after  which  the  finer  strips 
and  disks  should  be  employed  to  bring  gold  and  tooth  sub- 
stance to  an  exact  level  at  the  cavo-surface  angle  for  the  entire 
cavity  outline. 

Finishing  strips  in  the  proximal.  To  reduce  the  quantity  ol 
gold  from  contact  point  to  the  gingival,  a  coarse  finishing 
strip  sufficiently  narrow  to  reach  from  the  gingival  outline  to 
near  the  contact  point  only,  is  of  advantage.  This  strip  is  in- 
troduced by  sharpening  one  end  and  passing  through  the  em- 
brasure below  contact  point  and  then  drawn  back  and  forth 
till  the  desired  surface  is  secured. 

Fine  narrow  linen  strips  are  then  used  in  the  same  way  to 
give  a  final  finish  to  this  place  of  difficult  access. 

When  the  entire  cavity  outline  has  been  exposed  and  the 
surface  otherwise  made  ready  for  the  final  finish  the  separator 


220  ESSENTIALS  OP  OPERATIVE  DENTISTRY 

should  be  tightened  another  degree,  when  it  will  be  found 
that  a  broad  fine  linen  strip  will  easily  pass  contact  point. 
This  should  be  given  three  or  four  sweeps  with  this  broad 
strip  not  too  tightly  drawn,  when  the  contact  point  should 
be  considered  finished. 

The  separator  should  be  gradually  loosened  and  removed. 
The  rubber  dam  removed  and  the  filling  tested  for  occlusion 
and  articulation  and  properly  shaped.  The  filling  should  then 
receive  a  thorough  finish,  with  wood  points,  leather  wheels 
and  tooth  cleaning  brushes,  carrying  first  pumice  then  whiting, 
till  the  surface  of  the  filling  is  as  smooth  as  the  external 
enamel  surface. 


MANIPULATION  OF  AMALGAM  221 


C  H  A  P  T  E  R  X  X  X  V  I. 

Manipulation  of  Amalgam  in  the  Making  of  a  Filling, 

Definition.  Amalgam  is  a  composition  of  mercury  with  one 
or  more  other  metals.  It  is  most  commonly  combined  with 
two  or  more  other  metals  which  have  been  previously  alloyed 
and  finely  divided  either  as  shavings  or  fillings  to  facilitate 
union  with  the  mercury. 

History.  .Amalgam  for  the  filling  of  teeth  was  introduced 
into  France  about  the  year  1826  by  M.  Teveau  which  he  called 
"silver  paste."  This  was  composed  of  silver  and  mercury 
alone,  and  must  have  given  very  unsatisfactory  results  as  com- 
pared with  those  secured  in  the  use  of  our  modern  alloys. 

Reception.  The  use  of  amalgam  was  given  a  most  unwel- 
come reception  by  the  profession  at  large,  while  the  converts 
of  the  "new  process"  were  equally  emphatic  in  their  praise  of 
the  new  filling  which  "would  certainly  cheapen  dentistry,  and 
harm  the  profession."  But  time  has  proven  amalgam  a 
blessing  to  the  poorer  classes  in  that  it  brings  dentistry  within 
the  reach  of  all  purses  and  has  thereby  proven  of  advantage  to 
the  dental  profession  by  broadening  its  field  of  usefulness. 

While  amalgam  has  many  faults  and  should  generally  be 
avoided  when  finance  will  permit,  the  fact  still  remains  that 
more  teeth  have  been  saved  through  its  use  than  with  any 
other  filling  material. 

However  the  percentage  of  salvage  is  greater  with  gold  and 
forces  amalgam  to  second  place. 

The  properties  of  amalgam  which  render  it  of  value  as  a 
filling  material  are :  First,  its  plasticity  eliminating  access 
form,  in  cavity  preparation,  and  making  possible  the  building 
up  of  lost  contours  in  inaccessible  places  in  the  mouth,  where 
convenience  and  access  forms  are  hard  to  secure,  sufficient  for 
the  manipulation  of  gold  either  cohesive  or  as  an  inlay. 


222  ESSENTIALS  OF  OPERATIVE  DENTISTRY 

Second.  Its  property  of  being  but  slightly  affected  by  the 
oral  fluids,  is  fairly  stable  as  to  bulk  and  shape;  and  last,  but 
not  least  in  the  minds  of  many  patients,  we  are  sorry  to  say,  is 
its  cheapness,  as  most  dentists  see  fit  to  build  fillings  of  amal- 
gam for  a  much  smaller  fee  than  gold. 

The  objections  to  amalgam  are :  Its  tendency  to  discolor 
both  as  to  its  exposed  surface,  and  the  teeth  with  which  it  has 
been  filled  due  to  slight  leakage  with  old  fillings ;  it  has  a  com- 
paratively large  expansion  and  contraction  range ;  its  contin- 
ued flow  under  load ;  poor  edge  strength ;  its  spheroiding  dur- 
ing setting,  when  not  properly  mixed  from  a  perfect  alloy.  It 
is  also  liable  to  injury  between  the  time  of  introduction  and 
complete  setting  through  carelessness  of  either  dentist  or  pa- 
tient. 

The  extent  of  expansion  and  contraction  of  amalgam  is  not 
under  the  control  of  manipulation  by  the  operator,  but  is  con- 
trolled by  the  composition  of  the  alloy  both  as  to  materials 
used  and  their  proportions ;  as  well  as  the  method  of  their 
preparation. 

The  flow  of  amalgam  under  pressure  is  the  term  applied  to 
the  tendency  of  amalgams  to  flatten  or  move  from  under 
stress. 

Most  metals  will  yield  or  flatten  under  a  given  stress  in  pro- 
portion to  the  load  up  to  a  given  point,  and  then  cease  unless 
the  weight  is  increased.  However  amalgam  continues  to  yield 
as  long  as  the  pressure  is  continued  even  though  it  is  not  in- 
creased. 

This  peculiarity  in  amalgam  explains  the  phenomenon  often 
observed  in  the  mouth.  Amalgams  differ  as  to  the  amount  of 
force  necessary  to  produce  flow,  3^et  the  peculiarity  is  ex- 
hibited by  all  amalgams. 

Edge  strength  in  a  filling  is  the  term  applied  to  the  resist- 
ance, a  filling  shows  to  stress  upon  thin  margins,  as  that  por- 
tion of  a  filling  which  covers  the  marginal  bevel. 

Edge  Strength  in  Amalgam  depends :  First  upon  the  met- 
als entering  into  the  alloy.  The  greater  the  proportion  of  sil- 
ver entering  into  the  amalgam  up  to  75  per  cent  the  greater 


MANIPULATION  OF  AINIALGAM  223 

the  edge  strength.  Above  75  per  cent  it  becomes  more  brittle. 
Second.  The  edge  strength  depends  .upon  the  manner  of 
packing.  Third,  The  edge  strength  depends  upon  the  amount 
of  actual  union  between  mercury  and  alloy.  Fourth,  bulk  at 
margin. 

The  Maximum  Strength  will  be  obtained  when  the  alloy 
contains  just  enough  mercury  so  that  the  mass  will  take  the 
impression  of  the  skin  markings  after  prolonged  kneading  be- 
tween the  thumb  and  forefinger.  Any  more  or  any  less  weak- 
ens the  edge  strength. 

The  Length  of  Time  the  Alloy  Stands  has  an  effect  upon 
edge  strength,  as  amalgam  made  from  alloys  lose  their  edge 
strength  progressively  with  time,  the  more  rapidly  the  higher 
the  average  temperature. 

However  Aged  Alloys  show  less  variation  in  expansion,  con- 
traction, range  and  artificial  aging  is  resorted  to  for  this  rea- 
son and  is  done  by  anneaHng.  This  annealing  produces  an 
amalgam  that  shows  more  uniform  and  consistant  properties. 

Annealing  of  Amalgam  is  accomplished  by  subjecting  the 
alloy  when  freshly  cut  to  either  a  dry  or  moist  heat  ranging 
from  110  degrees  to  213  degrees  Fahrenheit  for  some  hours  or 
days.  The  lower  temperature  for  a  longer  period  produces  the 
best  results. 

Effect  of  Annealing.  The  artificial  aging  increases  the  con- 
traction, flow  and  ability  to  withstand  the  crushing  strain ;  the 
amalgam  requires  less  mercury,  and  sets  slower. 

The  Alloy  Showing  the  Least  expansion  and  contraction 
when  unannealed  is  composed  of  72  parts  silver  and  28  parts 
tin  and  may  be  modified  very  slightly  by  adding  a  small  per 
cent  of  copper  or  other  metals.  When  annealed  the  above 
formula  of  silver  tin  alloy  should  be  changed  to  76  silver  and 
24  tin,  to  get  a  stable  amalgam. 

The  Addition  of  5  Per  Cent  of  Gold  to  the  above  silver  tin 
alloy,  causes  it  to  set  slower;  flow  more;  take  less  mercury; 
increases  the  edge  strength  and  reduces  the  shrinkage. 

The  Addition  of  5  Per  Cent  of  Platinum;  darkens  the  fill- 


224  ESSENTIALS  OF  OPERATIVE  DENTISTRY 

ing";  materially  slows  the  setting;  causes  it  to  flow  badly  and 
increases  both  expansion  and  contraction. 

The  Addition  of  5  Per  Cent  of  Copper;  causes  it  to  set  quick- 
ly but  slower  when  annealed ;  increases  the  expansion ;  dimin- 
ishes the  flow  and  gives  the  greatest  edge  strength  of  all  formu- 
las. 

The  Addition  of  5  Per  Cent  of  Zinc ;  gi\'es  a  long  continued 
and  great  expansion ;  sets  more  quickly,  less  when  annealed ; 
flow  is  greatly  increased ;  color  improved ;  crushing  strength 
increased ;  takes  more  mercury  and  the  electrical  response  is 
greatly  increased,  a  feature  which  is  annoying  to  some  patients 
for  hours  or  days  after  the  introduction  of  an  amalg'am  con- 
taining zinc,  particularly  if  there  are  other  fillings  or  crowns  in 
the  mouth  alloyed  with  copper. 

Cavity  Preparation  for  Amalgam.  Many  of  the  failures  in 
the  use  of  amalgam  attributed  to  the  property  of  the  material 
used,  are  due  to  laxity  in  cavity  preparation,  many  believing 
that  thoroughness  is  unnecessary  in  this  particular.  This  is  a 
mistake.  The  preparation  of  a  cavity  for  the  reception  of 
amalgam  is  even  more  exacting  than  for  gold  as  the  operator 
is  dealing  with  a  filling  material  possessed  of  a  greater  number 
of  faults,  each  of  which  must  be  given  consideration,  and  the 
ca\'ity  so  prepared  as  to  minimize  these  to  the  greatest  degree. 
Amalgam  requires  less  access  in  awkward  localities  in  the 
mouth.  As  much  separation  is  required  in  proximal  fillings. 
Outline  form  must  receive  more  careful  consideration  as  the 
margins  must  be  farther  removed  from  positions  of  great  lia- 
bility to  caries,  as  well  as  stress. 

Flat  Seats  for  Fillings  are  even  more  imperative  than  with 
gold,  and  the  occlusal  step  must  be  broader  bucco-lingually. 
The  enamel  walls  must  be  finished  with  as  great  care,  with  a 
cavo-surface  angle  more  acute,  and  a  more  deeply  buried  bevel 
angle.  Cavities  must  have  more  retenti\'e  form.  All  this  is 
said  when  comparing  amalgam  and  cohesive  gold,  other  con- 
ditions presented  being  the  same. 

The  Rubber  Dam  is  very  essential  as  it  is  imperative  that 
amalgam  be  built  against  dry  freshly  cut  walls  and  margins. 
It  is  as  impossible  to  make  a  good  amalgam  filling  as  it  is  a 


MANIPULATION  OF  AMALGA^kl  225 

good  gold  filling  against  moist  walls.  The  residue  from  the 
saliva  upon  the  walls  will  show  leakage  more  quickly  with  the 
amalgam  filling  than  with  the  gold.  When  operators  come  to 
the  full  realization  of  this  fact  and  manipulate  all  amalgam 
fillings  with  as  great  care  as  gold,  with  reference  to  dry  con- 
ditions, the  frequent  failures  of  amalgam  will  be  materially 
lessened. 

The  Matrix.  All  cavities  filled  with  amalgam  must  have 
continuous  surrounding  walls.  This  will  necessitate  the  ad- 
justment of  the  matrix  in  cases  where  the  fourth  wall  is  miss- 
ing and  applies  to  all  class  II  ca\'ities  which  reach  the  occlusal 
surface. 

This  should  be  thoroughly  wedged  at  the  gingival,  to  pre- 
vent excess  contour  at  this  point  and  to  secure  additional  space 
that  contact  point  may  be  made  close.  The  matrix  should  be 
made  of  steel  as  thin  as  one,  one  thousandth  of  an  inch.  It 
should  be  made  to  encircle  the  tooth  firmly  either  by  ligaturing 
or  by  a  retaining  appliance  several  of  which  are  on  the  market. 
When  two  proximal  fillings  are  to  be  built  at  the  same  time 
and  in  the  same  proximal  space  two  matrices  are  necessary 
one  for  each  tooth  involved. 

Separation,  Preliminary  or  immediate  separation  is  just  as 
essential  in  the  use  of  amalgam  as  gold. 

Making  the  Proper  Proportions  of  Alloy  and  Mercury.  Each 

operator  should  test  his  favorite  alloys  and  determine  the  ex- 
act amount  of  mercury  for  a  given  quantity  of  alloy,  and  by 
the  use  of  a  pair  of  balances  be  able  to  always  mix  in  exactly 
the  same  proportions.  By  this  means  the  operator  is  able  to 
produce  the  best  product  by  having  the  amalgam  at  its  best. 
Ry  the  uniformity  he  becomes  familiar  with  the  habits  of  that 
particular  alloy. 

This  method  need  not  be  a  time-loser,  if  the  portions  of  al- 
loy  and  mercury  are  previously  jnit  up  in  separate  capsules 
ready  for  immediate  use.  In  early  practice  this  can  be  done 
by  the  dentist  himself  at  leisure  times  and  in  after  years  by  the 
assistant. 

Making  the  Mix.     Upon  the  thorough  incorporation  of  the 


226  ESSENTIALS  OF  OPERATIVE  DENTISTRY 

mercury  with  the  alloy  prior  to  placing  in  the  cavity  depends 
much  of  the  good  qualities  of  an  amalgam  filling.  Poorly 
mixed  alloys  have  little  strength.  Amalgamation  In  an  amal- 
gam filling  is  never  entirely  complete,  and  while  this  process 
is  going  on,  there  is  a  certain  amount  of  moleculaar  motion, 
which  tends  to  change  the  form  of  the  filling  as  a  whole.  A 
very  great  per  cent  of  this  union  may  be  induced  before  plac- 
ing the  filling  by  a  thorough  preliminary  mixing  and  kneading 
of  the  mass. 

To  this  end  the  alloy  and  mercury  should  be  put  into  a 
wedgewood  mortar  and  thoroughly  ground  together  till  the 
contents  seems  to  have  become  one  mass.  It  should  then  be 
removed  to  the  palm  of  the  hand  and  made  into  a  pellet  and 
then  transferred  to  the  thumb  finger  grasp  and  rolled  between 
the  fingers  with  sufficient  force  to  produce  a  decided  squeaking 
noise  sometimes  spoken  of  as  the  "cry  of  tin."  Either  too  lit- 
tle or  too  much  mercury  will  destroy  this  sound  which  should 
be  sought.  This  kneading  should  be  continued  till  the  maxi- 
mum plasticity  has  been  secured,  and  the  tendency  to  stiffen 
has  just  appeared. 

Wringing  Out  Excess  Mercury.  All  surplus  mercury  should 
be  expressed  as  soon  as  detected.  With  small  masses  this  is 
thoroughly  and  quickly  done  by  grasping  the  mass  between 
the  ball  of  the  thumb  and  the  tip  of  the  first  or  second  finger. 
The  flesh  of  the  fingers  should  entirely  cover  the  mass  from 
view.  Then  by  a  rocking  motion  keeping  the  mass  entirely 
co\ered  the  mercury  will  appear  from  between  the  fingers  and 
not  carry  with  it  any  appreciable  amount  of  the  alloy. 

If  the  mass  is  too  large  to  keep  entirely  covered  during  the 
process,  the  mass  should  be  placed  in  a  chamois  skin  and 
wrung  to  dryness. 

Amalgam  Pluggers.  The  packing  instruments  should  be  as 
large  as  can  be  well  used  in  the  cavity,  that  the  whole  mass 
may  receive  the  force  of  compression  at  each  effort.  The  face 
of  the  plugger  should  be  serrated  to  prevent  slipping,  A  ball 
burnisher  should  not  be  used  in  packing  amalgam,  but  is  in- 
tended for  finishing  to  contour. 


MANIPULATION  OF  A:\IALGAM  227 

Making  the  Filling.  The  cavity  should  be  in  complete  readi- 
ness to  receive  the  amalgam  as  soon  as  that  has  been  pre- 
pared. The  ball  of  amalgam  is  placed  upon  a  glass  slab  and 
split  in  several  parts  with  a  chisel.  The  size  of  the  portions 
will  depend  upon  the  orifice  of  the  ca\ity,  and  should  be  as 
large  as  can  be  handily  crowded  into  the  opening.  This  should 
be  immediately  compressed  upon  the  seat  of  the  cavity  with 
as  large  a  plugger  as  possible,  with  a  rocking  motion  and  as 
much  weight  as  the  circumstances  will  permit.  When  using  a 
point  that  is  much  smaller  than  the  cavity  the  same  wedging 
principle  used  in  packing  gold  should  be  employed  :  That  is, 
compress  the  central  portion  of  the  mass  first  and  against  the 
walls  last.  A  burnisher  should  not  be  used.  Neither  should 
the  burnishing  or  wiping  motion  be  used,  but  all  compressing 
force  should  be  directed  at  a  right  angle  to  the  base  wall. 

Trimming  Amalgam  Fillings,  After  packing  the  amalgam 
it  should  be  allowed  to  set  undisturbed  for  one  or  two  minutes, 
when  the  excess  may  be  cut  away  with  suitable  knives.  Gum 
lancet  No.  2  is  of  service,  also  the  discoid  and  cleoid  from 
"University  set"  are  good  as  well  as  the  large  spoon  excava- 
tors, which  are  adapted  for  use  on  the  occlusal  surface. 

Removal  of  Matrix.  The  matrix  should  then  be  removed  in 
proximal  ca\ities  by  drawing  to  the  buccal  while  pressing  the 
ball  of  the  finger  gently  on  the  occlusal  surface. 

This  will  prevent  the  matrix  from  traveling  occlusally  in  the 
process  of  reomval.  The  rubber  dam  should  then  be  removed, 
at  the  same  time  cautioning  the  patient  not  to  close  the  jaws. 
Then  immediately  request  patient  to  cautiously  close  the  teeth 
stopping  the  instant  they  feel  the  presence  of  the  filling  be- 
tween the  teeth,  which  will  be  the  case  if  excess  contour  has 
been  built.  Request  the  patient  with  teeth  in  this  position  to 
give  the  jaws  a  gentle  side  movement.  This  will  result  in 
burnishing  the  spots  of  contact  when  the  excess  should  be 
whittled  away  with  knife  edged  instruments. 

Amalgam  Should  Be  Cut  From  the  Margins,  to  the  filling 
which  is  right  the  reverse  from  the  travel  of  the  instrument  in 
cutting  gold  fillings.     If  the  cutting  instrument  moves  from 


228  ESSENTIALS  OF  OPERATIVE  DENTISTRY 

the  filling  to  the  ca\'o-surface  angle  with  amalgam  that  is  only 
partially  set,  it  is  liable  to  sink  too  deeply  into  the  suiDStance  of 
the  filling  and  expose  the  margin  as  it  crosses  over. 

Passing  Contact  Point.  In  proximal  fillings  of  amalgam 
nothing  of  any  description  should  ever  be  caused  to  pass  con- 
tact point  till  the  amalgam  has  completed  the  process  of  set- 
ting, as  one  such  attempt  forever  destroys  proper  contact,  and 
a  filling  so  treated  becomes  at  once  a  makeshift.  All  over- 
hanging amalgam  should  be  cut  away,  around  the  entire  cavity 
outline,  but  the  region  of  contact  point  should  be  entirely  ne- 
glected at  this  time,  and  left  for  final  shaping  during  the  pro- 
cess of  polishing.  Finally  the  filling  should  be  gently  wiped 
with  spunk  or  cotton. 

Polishing.  All  amalgam  fillings  should  receive  as  thorough 
and  careful  polishing  as  gold.  This  must  be  done  at  a  subse- 
quent sitting.  In  proximal  fillings  the  separator  should  be  ad- 
justed and  the  contact  point  properly  formed  and  polished. 

For  this  work  abradents  of  only  the  finest  nature  should  be 
employed.  Burs,  carborundum  stones,  coarse  strips  and  disks 
only  do  harm  and  prolong  the  operation.  Fine  strips,  disks, 
wood  points  and  leather  wheels  using  first  pumice  then  whit- 
ing, and  lastly  the  tooth  polishing  rubber  cups. 


THE  USE  OF  CEMENTS  22S> 


CHAPTER    XXXVII. 

The  Use  of  Cements  in  Filling  Teeth. 

Varieties.  There  are  five  main  varities  of  cement  available 
for  use  in  the  operation  of  filling  teeth  ;  cylicate  cement,  ox- 
vphosphate  of  zinc,  oxychloride  of  zinc,  sulphate  of  zinc  and 
oxyphospate  of  copper. 

Cavity  preparation  for  cement  when  the  entire  filling  is  to 
be  of  cement  is  not  unlike  that  for  any  other  filling,  except 
that  the  cavo-surface  angle  is  left  the  same  as  that  produced 
by  the  cleavage  of  the  enamel,  omitting  the  marginal  bevel. 
The  cavity  should  be  given  the  usual  retention  form,  and  the 
matrix  must  be  employed  in  cavities  to  supply  the  missing 
wall  that  the  cement  may  be  introduced  with  pressure  to  con- 
dense and  create  close  adaptation  to  walls. 

The  rules  given  for  dryness  in  the  manipulation  of  gold  and 
amalgam  are  also  of  force. 

The  Cylicate  Cements  have  been  evolved  in  an  effort  to  pro- 
duce a  cement  that  would  more  nearly  harmonize  with  the 
color  of  the  teeth;  to  better  withstand  the  action  of  the  oral 
fluids  and  the  abrading  effects  of  mastication.  These  are  at 
this  time  being  tested  by  the  profession  generally  with  a  very 
wide  difiference  of  opinion  as  to  their  value.  It  would  seem 
that  as  far  as  it  has  been  tested  this  cement  is  possessed  of  a 
very  wide  range  of  results  as  to  its  durability,  as  its  behavior 
has  been  most  erratic.  It  is  hoped  that  more  uniform  results 
may  be  obtained  in  the  future.  The  cylicates  have  proven 
scarcely  more  permanent  than  the  oxyphosphate  cement. 

A  great  variety  of  shades  has  been  produced  which  gives 
it  a  slight  advantage  in  this  respect. 

The  oxyphospate  of  zinc  has  many  uses  in  the  cavities  of 
teeth  as  a  partial  filling  and  in  some  instances  for  the  complete 
filling.    As  it  is  a  poor  conductor  it  is  an  excellent  agent  as  an 


230  ESSENTIALS  OF  OPERATIVE  DENTISTRY 

intermediate   between    metal   fillings   and   nearly   approached 
pulps. 

Its  adhesive  quality  gives  it  great  value  as  a  means  of  adding 
retention  to  all  kinds  of  metal  fillings.  This  quality  together 
with  its  harmonious  color  with  tooth  substance  makes  it  in- 
valuable for  lining  weakened  enamel  walls  which  have  lost 
much  of  their  supporting  dentine. 

Its  chief  fault  is  its  tendency  to  dissolve  in  the  fluids  of  the 
mouth,  which  renders  it  comparatively  temporary.  However 
there  is  a  considerable  variation  in  its  behavior  in  different 
mouths,  in  some  instances  wearing  for  years. 

Oxychloride  of  zinc  is  indicated  in  pulpless  teeth  to  fill  the 
pulp  chamber,  after  the  canals  have  been  previously  filled  with 
gutta-percha,  and  for  the  lining  of  cavities  for  the  preservation 
of  color  where  adhesiveness  is  not  of  importance.  It  is  not  in- 
dicated in  teeth  with  nearly  approached  vital  pulps  or  as  a  root 
filling  on  account  of  its  irritating  properties. 

Sulphate  of  zinc  when  pure  is  the  least  irritating  of  all  ce- 
ments and  is  one  of  the  best  materials  for  pulp  protection.  A 
pulp  capping  of  the  sulphate  of  zinc  is  of  most  universal  ap- 
plication. 

Oxyphosphate  of  copper  is  especially  indicated  in  remote 
cavities  on  the  necks  of  teeth  occasioned  by  gum  recession 
Cavities  which  are  so  ill  defined  that  the  use  of  amalgam  or 
gutta-percha  is  difficult,  may  be  successfully  filled  with  this 
preparation  of  copper. 

It  can  be  made  to  adhere  very  tenaciously  to  the  walls  of  a 
cavity  obviating  much  cutting.  Oxyphosphate  of  copper  is 
also  indicated  in  the  small  cavities  in  the  deciduous  teeth. 

It  is  claimed  to  exert  a  therapeutic  influence  upon  the  tooth 
substance  preventing  farther  decay. 

Manipulation  of  oxyphosphate  of  zinc  cement.  The  method 
of  mixing  this  cement  is  not  in  the  least  difficult,  yet  certain 
details  are  essential.  The  slab  should  be  clean.  Smooth  glass 
is  preferred.  The  spatula  should  be  flat  with  the  side, 
slightly  convex. 

Agate    is    the    best    material    as    it    is    not    acted     upon 


THE  USE  OF  CEMENTS  231 

by  the  liquid.  The  Hquid  and  powder  should  be  placed 
upon  the  slab  separately.  The  drop  of  liquid  should  be  car- 
ried there  by  the  use  of  a  small  glass  rod.  The  spatula 
should  never  be  immersed  in  the  bottle  to  obtain  more  fluid 
a  practice  which  will  destroy  the  efficiency  of  the  liquid.  Crys- 
tallized portions  should  be  carefully  wiped  of¥  the  mouth  of 
the  bottle  as  soon  as  detected. 

Plan  of  spatulating.  The  powder  should  be  added  to  the 
liquid  a  little  at  a  time  and  each  portion  thoroughly  rubbed 
by  a  swinging  circular  movement  of  the  spatula  upon  the  slab. 
This  rubbing  should  be  rapid  and  vigorous  and  the  powder 
added  till  the  consistency  desired  is  obtained.  For  lining 
cavities  where  thin  layers  are  desired  which  are  very  adhesive 
the  cement  will  prove  correctly  mixed  when  it  shows  slight 
stringiness  and  when  the  first  stickiness  appears  as  shown  by 
the  slight  resistance  offered  the  spatula  in  its  movement  over 
the  slab.  Where  the  entire  falling  is  to  be  of  cement  more 
powder  should  be  added  and  the  spatulation  vigorously  con- 
tinued till  the  cement  materially  resists  spatulation  and  the 
mass  is  the  consistency  of  freshly  made  putty.  When  cement 
is  of  the  consistency  desired  no  time  should  be  lost  in  placing 
it  in  position,  and  it  should  be  allowed  to  harden  undisturbed. 
If  the  cement  is  to  form  the  entire  filling  and  as  much  per- 
manency as  possible  is  desired  it  should  be  crowded  to  place 
with  some  force  and  rapidly  shaped  up.  As  soon  as  crystal- 
lization begins  it  should  not  be  disturbed  by  manipulation  till 
it  has  fully  hardened,  when  it  should  be  smoothed  and  polished 
with  fine  strips  and  disks. 


232  ESSENTIALS  OF  OPERATIVE  DENTISTRY 


C  H  A  P.T  E  R  X  X  X  V  1 1 1. 

The  Use  of  Gutta-Percha  in  Filling  Teeth. 

Gutta-Percha  has  its  place  in  various  operations  upon  the 
teeth.  It  is  not  acted  upon  by  the  fluids  of  the  mouth  and  is 
quite  permanent  when  placed  in  locations  protected  from  the 
force  of  mastication. 

It  is  a  good  tooth  preserver  as  decay  does  not  readily  take 
place  in  cavities  so  filled. 

Base  Plate  Gutta-Percha  is  the  best  form  to  be  had.  It 
comes  in  the  white  and  pink  colors,  the  last  named  being  the 
most  durable  in  positions  exposed  to  wear  as  it  gets  the  harder 
upon  cooling. 

Filling  Cavities  with  Gutta-Percha.  This  material  is  indi- 
cated in  subgingival  cavities,  both  buccal  and  proximal,  where 
a  filling  that  is  a  very  poor  conductor  of  heat  and  cold  is  de- 
sired, on  account  of  close  proximity  to  the  pulp,  the  pulp  be- 
ing not  yet  exposed. 

Also  indicated  for  those  distressing  cases  where  there  is  a 
decay  started  in  the  occlusal  of  a  lower  third  molar  which  has 
erupted  with  its  occlusal  surface  at  an  angle  of  about  forty-five 
degrees  to  the  distal  of  the  second  molar.  Such  cases  cannot 
as  a  rule  be  properly  extended  to  check  decay  in  the  use  of 
amalgam  or  gold. 

The  gutta-percha  filling  will  check  decay  and  if  renewed  at 
stated  periods  will  produce  sufficient  separation  for  correct 
filling  or  to  render  extraction  easy. 

Method  of  preparation  and  filling.  The  cavity  should  be 
freed  of  all  decay  and  the  cleavage  of  the  enamel  secured, 
omitting  the  marginal  bevel.  The  cavity  should  be  sterilized 
and  dried,  then  slightly  moistened  with  campho-phenique  or 
eucalyptol.  The  gutta-percha  warmed  and  immediately 
crowded  to  position.  Care  should  be  taken  that  the  material  is 


THE  USE  OF  GUTTA  PERCHA  233 

not  over  heated  as  slight  burning  destroys  the  durabil- 
ity of  rubber. 

The  gutta-percha  should  be  introduced  in  one  piece  suf- 
ficiently large  to  a  little  more  than  fill  the  cavity.  The  sur- 
plus being  wiped  off  flush  with  the  cavity  margins  with 
warmed  burnishers.  Finally  the  surface  should  be  wiped  with 
a  cotton  ball  carrying  chloroform. 

For  root  fillings.  The  gutta-percha  is  dissolved  in  chloro- 
form to  the  consistency  of  molasses,  and  carried  to  the  canals 
b}'  dipping  a  smooth  broach  in  the  container.  The  canals 
should  have  been  previously  flooded  with  oil  of  eucalyptol, 
and  the  chlora-percha  mixed  with  the  eucalyptol  in  the  root 
canal  resulting  in  what  may  be  termed  euco-percha.  The 
eucalyptol  may  be  added  to  the  chlora-percha  in  the  bottle,  but 
the  method  given  first  is  for  various  reasons  the  better. 

For  canal  points.  Gutta-percha  is  the  standard  material  for 
canal  points  which  should  be  at  hand  in  various  sizes  to  suit 
all  cases. 

These  may  be  manufactured  by  the  dentist,  but  with  little 
economy,  as  they  are  well  made  by  machinery.  Those  which 
are  flattened  on  the  larger  end  being  the  most  handy  to  use. 
Such  may  be  had  from  your  dealer,  or  the  assistant  can  flatten 
them  as  purchased  by  placing  them  on  a  glass  mixing  slab  and 
pressing  each  large  end  with  a  smooth  cold  steel  instrument. 

Slow  separation.  Gutta-percha  for  slow  separation  in  prox- 
imo-occlusal  cavities  is  unexcelled,  the  force  of  mastication 
doing  the  work  slowly  but  surely.  This  fact  prohibits  the  use 
of  gutta-percha  as  a  permanent  filling  in  class  II  cavities. 

Temporary  stopping,  as  purchased  from  the  dealer,  is  gutta- 
percha to  which  wax  has  been  added  to  render  it  more  plastic 
when  warmed.  This  is  ifleal  for  sealing  in  dressings,  except- 
ing when  arsenic  has  l)ccn  used,  in  which  case  poorly  mixed 
amalgam  is  better. 


234  ESSENTIALS  OF  OPERATIVE  DENTISTRY 


CHAPTER  XXXIX 

Tin  As  a  Filling  Material 

History.  The  first  use  of  tin  as  a  material  for  filling 
teeth,  would  seem  to  date  back  to  about  1780  and  was  much 
written  about  as  a  tooth  preserver  for  the  century  following. 
After  the  introduction  of  amalgam  in  1826  there  seemed  to 
have  been  much  rivalry  between  the  two  substances,  amalgam 
gaining  the  favored  position  over  tin. 

At  the  World's  Columbian  Dental  Congress,  in  Chicago, 
1893,  as  will  be  seen  by  the  report,  many  dentists  of  national 
repute  went  on  record  as  classifying  tin  as  one  of  our  best 
tooth  savers  and  deplored  the  fact  that  its  value  was  being 
lost  sight  of. 

The  late  Dr.  W.  C.  Barrett  expressed  himself  so  emphati- 
cally as  to  say  "Tin  is  as  cohesive  as  gold,  and  if  everything 
was  blotted  out  of  existence  with  which  teeth  could  be  filled, 
except  tin,  more  teeth  would  be  saved."  This  may  he  putting 
it  a  little  too  strong,  but  the  fact  remains  that  more  teeth 
would  be  permanently  saved  if  a  more  general  use  of  tin  was 
common  with  the  profession  today. 

Therapeutic  Value  of  a  Tin  Filling.  Of  all  our  filling  ma- 
terials there  are  only  two  for  which  any  therapeutic  value  is 
claimed.  All  others  prevent  the  farther  loss  of  tooth  sub- 
stance by  exclusion ;  mechanically  shielding  the  defenseless 
tooth  substance  from  the  dissolving  properties  of  the  products 
of  fermentation. 

The  Therapeutic  Action  of  Tin  is  probably  due  to  the  for- 
mation of  the  sulfid  of  tin  which  is  caused  by  the  presence  of 
sulfuretted  hydrogen  from  the  decomposition  of  food  sub- 
stance. The  dentinal  walls  of  a  cavity  which  has  been  filled 
with  tin  for  some  time,  turn  brown  or  black  and  seem  to 
have  undergone  a  structural  change  rendering  them  quite  im- 


TIN  AS  A  FILLING  MATERIAL  235 

pervious  to  decay,  and  very  hard  to  excavate  with  hand  instru- 
ments or  the  engine  bur. 

Discoloration.  In  some  mouths  tin  turns  black  not  only 
upon  its  external  surface  but  this  color  is  in  a  measure  trans- 
mitted to  the  tooth  substance,  a  fact  v^rhich  is  one  of  the  great- 
est objections  to  its  use  and  debars  it  from  exposed  positions 
in  the  anterior  portion  of  the  mouth.  In  other  mouths  there 
seems  to  be  little  discoloration  the  filling  remaining  polished 
and  of  a  light  color. 

The  Amount  of  Discoloration  seems  to  bear  no  relation  to 
its  permanency  as  to  bulk  or  as  a  tooth  preserver. 

Thermal  Conductivity.  Tin  is  only  one-fourth  as  good  a 
conductor  of  heat  and  cold  as  gold,  hence  its  indicated  use 
under  gold  fillings  in  deep  seated  caries  with  vital  pulp. 

Indicated  in  Rapid  Caries.  In  caries  of  a  light  or  white 
color  indicating  the  most  rapid  form  of  decay,  tin  is  of  pecu- 
liar advantage  particularly  in  regions  removed  from  view  and 
protected  from  the  wear  of  mastication. 

Tin  in  the  Teeth  of  Children.  There  is  no  better  material  for 
filling  the  teeth  of  children  than  tin.  The  principle  of  mechan- 
ical exclusion  depended  upon  with  other  filling  materials  to 
prevent  recurrent  decay  does  not  seem  to  be  sufficient  in  the 
rapid  form  of  decay  met  with  in  both  temporary  and  perma- 
nent teeth  in  the  mouths  of  children  particularly  during  the 
age  of  rapid  development  as  found  before  the  age  of  fifteen  or 
sixteen.  The  additional  advantage  of  the  therapeutic  influ- 
ences of  tin  seems  to  be  sufficient  to  check  this  rapid  progress 
of  decay  till  a  period  is  reached  when  the  process  of  tooth 
destruction  is  less  apparent,  due  to  more  hygienic  conditions 
in  the  oral  cavity. 

Cavity  Preparation  for  Tin.  The  cavity  preparation  for 
the  use  of  tin  is  not  unlike  that  given  in  the  chapters  on 
cavity  preparation  by  classes  for  cohesive  gold.  It  will  be  of 
advantage  if  the  convenience  angles  are  a  little  more  distinct, 
and  the  general  retentive  form  throughout  should  be  em- 
phasized. The  bevel  angle  should  be  a  little  more  deeply 
buried  as  the  edge  strength  is  not  as  good  as  hammered  gold. 


236  ESSENTIALS  OF  OPERATIVE  DENTISTRY 

However  the  edge  strength  is  better  than  amalgam.  Tin  has 
no  tendency  to  spheroid  Hke  amalgam.  Its  flow  is  similar  to 
that  of  gold  but  greater  with  the  same  given  load  and  like  gold 
it  is  capable  of  being  so  condensed  that  it  will  stand  repeated 
stress  of  a  given  load  within  a  limited  range  and  show  no 
flow. 

Forms  of  Tin.  Formerly  the  only  form  of  tin  to  be  had 
for  this  purpose  was  the^  sheet  tin.  This  was  manipulated  in 
much  the  same  way  as  cohesive  gold  except  that  It  required 
no  annealing. 

It  was  then,  and  is  yet  sometimes  combined  with  gold  by 
rolling  a  sheet  of  pure  tin  with  a  sheet  of  annealed  cohesive 
gold  into  rolls,  the  gold  on  the  outside  and  condensed  in  the 
usual  manner  using  a  large  proportion  of  hand  pressure. 

At  present  there  is  on  the  market  a  form  of  tin  prepared  in 
the  shreds,  which  appears  like  a  mass  of  coarse  silver  colored 
hair.  This  is  removed  from  the  tube  and  shaped  into  pellets 
of  suitable  size  and  placed  in  the  cavity  in  the  manner  one 
would  place  pellets  of  gold. 

Methods  of  Introduction.  The  rubber  dam  or  other  ef- 
ficient means  of  dryness  must  be  used.  When  one  of  the  sur- 
rounding walls  is  missing  as  in  proxo-occlusal  cavities  in  bi- 
cuspids and  molars  (class  2)  the  matrix  must  be  in  place. 
The  first  pellet  of  tin  introduced  should  completely  cover  the 
base  of  the  cavity  and  be  thoroughly  condensed  by  good 
steady  hand  pressure,  with  points  at  least  one  square  milli- 
meter in  size  employing  the  rocking  motion.  The  points 
should  have  deep  serrations  and  so  stepped  as  to  include  the 
entire  surface. 

This  hand  pressure  should  be  followed  with  the  mallet 
force  using  a  plugger  point  of  medium  serrations  and  the  sur- 
face entirely  gone  over.  A  new  pellet  may  now  be  applied 
and  the  plan  just  given  repeated.  If  the  filling  is  to  be  en- 
tirely of  tin  the  cavity  should  be  filled  to  excess  and  by  a  pro- 
cess of  burnishing,  condensed  and  rubbed  to  the  size  desired. 
This  last  method  gives  a  surface  of  the  greatest  density  pos- 
sible. 

Tin  and  Gold.     When  the  filling  is  to  be  completed  with 


TIN  AS  A  FILLING  MATERIAL  237 

cohesive  gold  little  dependence  should  be  put  upon  the  gold 
adhering  to  the  tin  as  the  union  is  only  slight.  With  a 
round  pointed  instrument  new  convenience  angles  should  be 
made  in  the  substance  of  the  tin  near  the  line  angles.  The 
remainder  of  the  cavity  should  be  retentive  independent  of 
the  space  occupied  by  the  tin. 

Tin  and  Amalgam.  No  special  care  is  needed  when  the  fill- 
ing is  to  be  completed  with  amalgam.  Amalgamation  takes 
place  in  that  portion  of  the  tin  next  to  the  amalgam  proper 
and  the  union  is  quite  strong  even  more  than  tin  to  tin.  The 
amalgam  should  if  possible  be  more  thoroughly  mixed  and 
the  process  of  kneading  prolonged  that  all  amalgamation  pos- 
sible be  secured  before  contacting  with  the  tin  as  the  tin 
will  take  up  some  of  the  mercury  from  the  amalgam  for  which 
it  has  a  great  affinity.  This  is  liable  to  injure  the  amalgam 
as  to  strength  unless  the  mixing  has  been  thorough.  The 
use  of  tin  and  amalgam  is  not  advised  where  the  surface  of 
the  tin  is  to  be  exposed  by  forming  any  portion  of  the  con- 
tour as  the  presence  of  the  mercury  absorbed  causes  the  tin 
to  rapidly  disintegrate.  Gold  should  be  used  for  topping  in 
such  cases. 

Tin  in  Bifurcated  and  Punctured  Roots,  When  through 
decay  or  by  accident  the  cavity  extends  to  the  exposure  of 
the  peridental  membrane  the  use  of  tin  has  no  substitute. 
The  opening  should  be  rendered  as  clean  as  possible,  sterilized 
and  dried.  The  opening  should  be  covered  with  a  mat  of  pure 
tin  made  from  folded  sheets,  being  lightly  burnished  to  place 
and  covered  with  amalgam  and  the  cavity  finished  with  the 
desired  material. 


238  ESSENTIALS  OP  OPERATIVE  DENTISTRY 


CHAPTER  XL. 

Combination  Fillings, 
Definition.     A  combination  filling-  is  a  filling  composed  of 
two   or  more   distinct  substances   introduced   into  the   cavity 
separately. 

Objects  of  a  Combination.  The  object  of  combining  vari- 
ous materials  in  the  filling  of  a  tooth's  cavity  is  to  secure  a 
perfect  filling.  One  possessed  of  all  virtues,  and  no  faults. 
Many  such  combinations  of  material  meet  this  demand  in  a 
large  measure  by  bringing  into  service  the  strong  features  of 
each  material,  and  at  the  same  time  nullifying  the  faults  of 
all  material  entering  into  the  construction. 

Since  dentistry  has  been  raised  to  the  dignity  of  a  science 
there  has  been  a  diligent  search  to  discover  a  filling  material 
which  possesses  the  virtues  of  all  and  the  faults  of  none  in 
present  use.  At  the  present  time  this  is  more  nearly  reached 
by  the  various  combinations  possible  with  the  usual  distinct 
materials.  If  perchance  the  ideal  filling  is  ever  produced, 
dentistry  will  at  once  become  much  simplified  as  to  methods 
of  procedure. 

Single  Materials  Used  as  a  Filling.  There  are  only  two 
filling  materials  now  in  use  which  are  used  in  their  pure  state. 
Pure  gold  and  pure  tin,  and  there  are  many  instances  where 
these  combined  either  with  each  other  or  with  other  materials, 
will  produce  better  results  than  when  used  alone. 

Gold  and  Tin  Combination.  This  combination  is  of  service 
in  large  cavities  class  2  which  are  subgingival  and  in  large  oc- 
clusal cavities  in  molars  where  the  pulpal  wall  is  deep  and 
rounded.  In  this  combination  the  tin  should  be  placed  in. 
the  cavity  first  and  thoroughly  condensed,  and  the  filling  com- 
pleted with  cohesive  gold. 


COMBINATION    FILLINGS  239 

In  class  2  the  tin-  should  cover  the  gingival  wall  at  least  one 
millimeter  deep  and  be  condensed  to  place  with  the  matrix  in 
position. 

Benefits  Derived.  Dentine  upon  which  has  been  built  a 
thoroughly  condensed  tin  filling  does  not  readily  decay.  (See 
chapter  39.)  By  completing  the  filling  with  gold  the  discolor- 
ation of  tooth  substance  is  avoided  and  the  gold  will  better 
resist  the  force  of  mastication. 

Gold  and  Cement.  The  object  of  this  combination  is  to 
produce  a  filling  that  is  adhesive,  will  protect  weak  walls,  and 
resist  the  fluids  of  the  mouth  and  the  force  of  mastication. 

Two  Methods  of  Combining.  There  are  two  methods  of 
producing  this  combination.  One  is  to  cast  the  filling  and 
lay  it  into  the  cement  covered  cavity  or  the  inlay.  The  other 
is  to  build  cohesive  gold  into  a  thin  mix  of  soft  cement  with 
which  the  walls  of  the  cavity  have  been  coated.  The  es- 
sential feature  of  both  is  that  the  cement  be  completely  cov- 
ered to  protect  it  from  dissolution  by  external  agencies,  as 
the  fluids  of  the  mouth  and  the  effects  of  wear. 

When  Indicated.  The  inlay  combination  is  indicated  in 
large  cavities  of  easy  access.  The  built-in  method  of  com- 
bination is  indicated  in  small  cavities  of  more  difficult  access, 
and  where  correct  cavity  formation  is  impossible  or  ill  ad- 
vised. When  using  this  method  convenience  angles  may  be 
omitted. 

Gold  and  Platinum.  This  combination  adds  to  the  many 
virtues  of  cohesive  gold  fillings  by  increasing  the  resistance 
of  the  filling  to  the  wear  of  mastication.  The  pure  gold  is 
first  used  as  it  is  capable  of  more  perfect  adaptation  to  the 
walls,  all  of  which  should  be  covered  before  taking  up  the 
platinized  gold.  The  contour  portion  should  be  made  of 
the  alloy.  This  alloy  comes  from  the  supply  house  in  sheets 
which  appear  to  be  jjurc  gold  except  the  color  is  a  little  lighter. 
This  foil  comes  in  three  numbers  1.  'i  and  '■>  the  Xo.  ."!  being  pre- 
ferable for  most  cases. 

The  rules  for  condensation  are  just  the  same  as  for  pure 
gold,  only  the  observance  of  each  s])ccific  rule  gixen   on  that 


240  ESSENTIALS   OF  OPERATIVE  DENTISTRY 

subject  is  more  emphaticalh-  demanded  here,  and  wlien  strict- 
ly followed  the  alloy  will  prove  as  easily  handled. 

Cohesive  Gold  and  Non-Cohesive  Gold  Combined.  By  this 
combination  much  time  is  saved  as  the  non-cohesive  gold 
may  be  introduced  in  greater  masses  than  the  cohesive.  Also 
the  soft  gold  will  make  a  closer  adaptation  to  walls  than  the 
cohesive. 

The  cohesive  gold  is  used  to  finish  the  contour  as  it  will 
better  resist  the  tortion  strain  and  the  effects  of  abrasion. 
Before  the  introduction  of  cohesive  gold  all  gold  fillings  were 
non-cohesive,  but  since  the  introduction  of  the  former  the 
art  of  filling  teeth  well  with  soft  gold  has  rapidly  declined,  so 
that  the  making  of  an  entirely  non-cohesive  gold  filling  is  now 
the  exception. 

Cement  and  Amalgam.  Results  similar  to  what  might  be 
termed  an  amalgam  inlay  is  produced  by  coating  the  prepared 
cavity  with  cement,  and  immediately  burnishing  into  this 
fresh  cement,  a  portion  of  the  amalgam.  The  enamel  mar- 
gins are  rendered  clean  again  b)'  freshly  cutting  them  with  a 
chisel  for  their  entire  outline  and  the  amalgam  filling  imme- 
diately finished  in  the  usual  way. 

The  Benefits.  This  combination  produces  a  filling  with 
the  virtues  of  an  amalgam  to  which  is  added  the  adhesion  of 
the  cement  and  the  protection  of  cavity  wall  from  fracture  and 
discoloration. 

Indicated  in  most  large  cavities  to  be  filled  with  amalgam. 
AA'eak  and  thin  w^alls  and  cavities  w^here  insufficient  retentive 
form  is  secured. 

Cement  and  Porcelain.  Cement  is  combined  with  porce- 
lain in  the  filling  of  teeth  for  the  purpose  of  making  the  filling 
adhesive. 

Or  turn  it  the  other  way,  the  porcelain  is  added  to  protect 
the  cement  from  dissolution. 

There  are  many  other  combinations  which  are  made  and 
to  advantage,  in  tooth  salvage.  It  is  entirely  improbable 
that  the  perfect  filling  material  Avill  ever  be  produced  as  the 


THE  USE  OF  PORCELAIN  241 

demands  are  so  varied  in  different  mouths,  and  in  different 
localities  in  the  same  mouth. 

We  are  more  nearly  able  to  meet  all  of  those  varying  con- 
ditions by  a  wise  selection  of  the  materials  to  be  used  in  each 
case  and  a  judicious  combination  will  go  far  to  produce  the 
perfect  filling  for  each  individual   cavity  as  presented. 


CHAPTER  XLL 

The  Use  of  Porcelain  in  Filling  Teeth. 

Definition.  A  porcelain  inlay  is  a  filling  made  of  dental 
porcelain  and  retained  in  position  by  cement 

A  Dental  Porcelain  is  a  solidified  mass  of  silicious  sub- 
stances suspended  in  a  flux  of  fused  silicate. 

Composition.  Dental  porcelain  is  composed ;  First  of  the 
basal  ingredients  which  are  refractory ;  Silex,  Kalin  and  Feld- 
spar. Second :  fluxes  used  to  increase  the  fusibility.  Those 
in  common  use  are  sodium  borate  (Na2  B4  07),  sodium  car- 
bonate (Na2  Co3),  potassium  carbonate  (K2  Co3)  or  glass. 
Third,  metals  and  oxides  used  as  pigments, 

Silex  is  the  oxide  of  silicon.  It  is  an  infusible  substance, 
insoluble  except  in  hydrofluoric  acid  and  is  used  to  give 
strength  to  the  porcelain.  It  gives  it  more  translucent  ap- 
pearance. 

Kalin  (2A  12  03  Si  02  3H2)  is  the  silicate  of  aluminum.  It 
is  added  to  porcelain  to  give  stability,  and  permits  unfused 
porcelain  to  be  molded  and  carved  in  the  shaping  of  contour. 

Feldspar  (A12  03  K2  O  6Si  02)  is  the  double  silicate  of 
aluminum  and  potassium.  It  forms  over  80  per  cent  of  the 
basal  mass  of  porcelain  and  adds  translucency. 

Pigments.  The  various  shades  and  colors  in  porcelain  are 
produced  by  the  addition  of  precipitated  gold,  platinum,  pur- 
ple of  cassius,  oxides  of  cobalt  titanium,  iron,  uraniimi 
and  silver,  producing  the  colors  of  red,  yellow,  blue,  green, 
brown  and  gray. 

(9) 


242  ESSENTIALS  OF  OPERATIVE  DENTISTRY 

High  Fusing  Porcelain.  By  high  fusing  porcelain  is  meant 
a  porcelain  that  requires  five  minutes  or  more  to  fuse  at  a 
temperature  exceeding  the  fusing  point  of  pure  gold. 

Low  Fusing  Porcelain.  A  porcelain  that  requires  less  than 
five  minutes  to  fuse  at  a  temperature  not  exceeding  the  fus- 
ing point  of  pure  gold.  This  division  is  one  of  creation  by 
the  manufactures  and  commonly  accepted  by  the  profession. 
However  the  distinction  is  only  relative  as  porcelain  has  no 
definite  fusing  point,  as  any  enamel  or  tooth  foundation  body 
may  be  fused  on  a  matrix  of  pure  gold  if  enough  time  is  given 
to  the  fusing  process. 

Effects  of  Fusing  at  Lower  Temperatures  and  a  Longer  Time. 

A  more  homogenous  mass  is  produced. 

A  more  characteristic  color  is  maintained. 

A  less  friable  filling  is  produced. 

A  High  Fusing  Porcelain  May  Be  Made  Low  Fusing  by 

repeated  fusing  and  grinding. 

In  Building  a  Filling  by  Layers  the  first  layer  should  be 
fused  to  a  state  of  high  biscuit  otherwise  the  process  of  fusing 
the  subsequent  layers  will  over-fuse  the  first. 

High  Biscuit  Fuse.  Heating  the  porcelain  sufficient  to 
obtain  shrinkage,  but  not  enough  to  glaze. 

Fine  Grinding.  The  more  finely  porcelain  is  ground  the 
lower  the  fusing  point  from  the  same  formula  and  the  greater 
the  shrinkage. 

Size  of  Mass.  The  larger  the  mass  the  greater  the  length 
of  time  required  to  fuse. 

Amount  of  Flux.  The  more  flux  a  porcelain  contains  the 
greater  the  liability  to  bubble,  which  liability  increases  as  the 
temperature  is  raised. 

Shrinkage  in  Fusing.  High  fusing  porcelains  shrink  from 
15  to,  25  per  cent.  Low  fusing  porcelain  shrinks  from  20  to 
35  per  cent. 

Spheroiding.  All  porcelains  have  a  great  tendency  to 
spheroid  when  over-fused. 


THE  USE  OF  PORCELAIN  243 

A  Basal  Body  is  porcelain  composed  of  basal  ingredients 
and  the  pigments. 

A  Foundation  Body  is  one  composed  of  basal  ingredients 
to  which  has  been  added  a  flux  to  increase  fusibility,  and  has 
been  ground  less  fine  than  enamel  body  to  raise  fusing  point 
and  give  stability  as  to  form. 

An  Enamel  Body  is  a  basal  body  which  has  been  more 
finely  ground  and  to  which  there  has  been  added  more  flux 
to  increase  fusibility. 

The  Advantages  of  the  Porcelain  Inlay.  When  skilfully 
made  they  more  nearly  harmonize  with  tooth  structure  in 
appearance.  Thermal  changes  do  not  readily  effect  the  pulp 
in  vital  cases  as  porcelain  is  not  as  good  a  conductor  of  heat 
and  cold  as  metal. 

Margins  of  cavities  well  filled  with  porcelain  are  not  read- 
ily attacked  by  caries,  as  cement  dissolves  out  of  the  margin 
to  a  depth  only  equal  to  the  breadth  of  the  line  exposed. 
Patients  are  relieved  of  sitting  with  the  rubber  dam  in  position 
for  protracted  periods. 

The  Disadvantages  of  the  Porcelain  Inlay.  The  friability 
of  porcelain  restricts  its  use  to  locations  removed  from  great 
stress.  It  is  necessary  to  omit  the  marginal  bevel  in  all 
cavities,  as  the  edge  strength  of  porcelain  is  no  greater  than 
full  length  enamel  rods. 

The  Cavo-surface  Angle  should  be  that  which  the  cleavage 
of  the  enamel  gives,  or  about  a  right  angle.  Its  greatest  dis- 
advantage is  the  fact  that  the  inlay  must  be  set  upon  unclean 
walls  as  the  whole  process  must  be  done  under  moist  condi- 
tions ;  moisture  being  necessary  to  maintain  the  color  of  the 
teeth  while  trying  to  imitate  their  shade.  This  prevents  the 
placing  of  the  filling  upon  freshly  cut  surfaces  which  have  not 
been  moistened,  the  greatest  enemy  to  all  inlay  fillings. 

Another  disadvantage  is  that  the  retention  of  the  porce- 
lain depends  upon  the  integrity  of  the  cement,  which  is  not 
wholly  protected  at  the  margins.  While  porcelain  inlays  fit 
the  cavity  from  a  practical  standpoint,  the  fact  exists  that 
they  never  exactly  fill  the  cavity,  the  cement  taking  up  the 


244  ESSENTIALS  OF  OPERATIVE  DENTISTRY 

space  resulting  from  the  misfit,  and  is  exposed  in  proportion 
to  the  amount  of  existing  space  at  the  margins. 

Indication  for  Porcelain  Filling.  In  cavities  in  the  anterior 
location  in  the  mouths  of  patients  who  have  an  appreciation 
for  aesthetic  qualities  of  dental  operations.  In  cavities  class  1 
when  they  occur  in  defects  on  labial  surfaces. 

Cavities  class  3  when  much  of  the  labial  wall  is  gone  and 
rather  strong  lingual  wall  remains. 

In  cavities  class  4,  plan  3,  vital  teeth  with  rather  thick  in- 
cisal  edge,  not  subjected  to  great  stress  in  articulation.  In 
"cavities  class  4  plan  1  when  proximating  tooth  is  not  in  po- 
sition as  when  the  missing  tooth  is  worn  upon  a  plate  or  is 
to  be  subsequently  replaced  with  a  crown  or  bridge. 
•  In  cavities  class  4,  plan  4,  in  upper  teeth  when  the  lingual 
surface  does  not  articulate. 

"  Gingival  third  (class  5)  in  anterior  teeth  exposed  to  view 
when  patient  smiles. 

■  In  cavities  class  6  on  the  six  anterior  teeth,  when  the  porce- 
lain is  built  to  a  thickness  of  at  least  two  millimeters,  and  in 
pulpless  lower  molars,  restoring  the  entire  occlusal  surface. 

Contra  Indications.  Porcelain  is  not  indicated  in  the  cav- 
ities not  above  mentioned,  and  in  all  locations  subject  to  great 
stress  and  where  good  access  form  is  difficult  to  obtain. 


PREPARATION  OF  CAVITIES  245 


CHAPTER   XLII. 

Preparation  of  Cavities   for  Porcelain  Inlays. 

The  filling"  of  teeth  with  porcelain  demands  some  change  in 
the  usual  and  accepted  form  of  cavity  preparation  for  other 
materials. 

Access  Form.  Access  form  reaches  its  maximum  in  por- 
celain filling.  Even  greater  access  is  required  than  for  the 
gold  inlay.  Hence  preliminary  separation  should  be  prac- 
ticed with  all  proximal  fillings,  before  forming  the  matrix, 
and  generally  mechanical  separation  is  of  advantage  when 
setting  the  filling. 

Outline  Form  for  Porcelain  Inlays.  Outlines  must  be  ex- 
tended to  regions  of  sound  enamel.  The  obtaining  of  full 
length  enamel  rods  supported  by  sound  dentine  Is  imperative. 
Extending  to  self-cleansing  margins  is  of  additional  advantage, 
yet  not  so  imperative  as  with  gold  filling,  as  secondary  decay 
is  not  as  liable  to  take  place  about  a  porcelain  filling. 

The  outline  should  not  follow  a  developmental  groove  nor 
cross  a  ridge  at  its  extreme  eminence.  Sharp  angles  in  out- 
line should  be  avoided.  Extension  for  prevention  as  applied 
to  the  embrasures  is  not  as  great  as  with  metal  fillings. 

Extension  for  Resistance  to  Stress  at  margins  is  more  es- 
sential than  with  gold,  due  to  the  friability  of  porcelain 
margins. 

Resistance  Form  for  Porcelain  Inlays.  The  rules  for  flat 
seats  for  all  fillings  applies  equally  to  porcelain  fillings.  The 
use  of  the  step  in  class  4  is  essential  to  give  added  resistance 
to  the  tipping  strain.  Margins  should  be  extended  to  loca- 
tions less  frequented  by  the  crushing  strain. 

Retention  Form  for  Porcelain  Inlays.  Maximum  retention 
form  is  required  in  all  directions  except  one,  till  the  matrix 


246  ESSENTIALS  OF  OPERATIVE  DENTISTRY 

has  been  formed  and  the  filling  made  ready  for  setting,  when 
retention  should  be  added  in  the  remaining  direction. 

Acute  line  and  point  angles  should  be  avoided;  all  angles 
being  rounded  angles  till  matrix  is  formed. 

Convenience  Form  for  Porcelain  Inlays.  The  filling  of 
teeth  with  porcelain  requires  more  cutting  for  convenience 
form  than  for  any  other  method.  This  fact  makes  such  fill- 
ings contra-indicated  many  times,  due  to  the  great  loss  of 
tooth  substance  necessary  to  properly  form  the  matrix  and 
introduce  the  filling.  Previous  separation  will  overcome  this 
cutting  to  a  large  extent  with  this  as  well  as  other  fillings. 

Finish  of  Elnamel  Walls.  All  finishing  of  enamel  walls 
must  be  completed  before  forming  the  matrix.  The  cavo- 
surface  angle  should  be  a  right  angle  as  the  strength  of  fused 
porcelain  is  about  equal  to  supported  enamel  margins.  If  a 
bevel  angle  exists  it  should  be  deeply  buried. 

Toilet  of  the  Cavity.  This  is  attended  to  the  same  as  with 
other  inlay  fillings  before  forming  the  matrix. 

Another  Cavity  Toilet  is  necessary  just  before  setting  the 
inlay.  This  consists  in  washing  the  cavity  with  chloro- 
form to  dissolve  any  oily  substances  adhering  to  the  cavity 
walls.  This  is  followed  with  absolute  alcohol  and  rnoderately 
dried.  Excessive  desiccation  is  not  required  and  in  fact 
should  not  be  practiced  as  the  integrity  of  the  cemental  sub- 
stance in  the  enamel  is  injured  and  liability  to  marginal' 
checking  increased. 

Preparation  of  Cavities  Class  I.  Defects  in  enarriel.  Por- 
celain is  indicated  in  cavities  on  the  labial  surfaces  of  the  six 
anterior,  due  to  faulty  enamel.  These  are  shown  as  small 
orifices  in  the  enamel  surface,  generally  rounded  in  form 
and  is  the  result  of  imperfect  development.  The  cavity 
should  be  not  less  than  two  millimeters  in  width  at  its  nar- 
rowest point.     Smaller  than  this  hinders  proper  working. 

Avoid  the  Exact  Circle  in  outline,  as  this  will  bewilder  the 
operator  as  to  the  position  when  setting.  In  case  the  outline 
is  so  near  a  circle  as  to  make  position  questionable,  the  axial 


PREPARATION  OF  CAVITIES  247 

wall  should  have  a  small  rounded  pit  at  one  side  to  guide 
operator  in  setting. 

The  Axial  Wall  should,  in  large  cavities,  be  the  miniature 
of  the  tooth  surface  in  which  it  occurs.  The  axial  wall  of 
small  cavities  should  have  a  rounded  groove  cut  around  the 
entire  circumference. 

The  Surrounding  Walls  should  meet  the  axial  at  an  obtuse 
angle  to  relieve  any  undercuts  before  matrix  is  formed. 
When  inlay  is  ready  to  set  give  the  cavity  retentive  form  by 
making  the  base  line  angles  acute. 

Cavities  in  Proximal  of  Bicuspids  and  Molars.  Class  II. 
Experience  has  taught  that  porcelain  is  not  indicated  in  this 
class  of  cavities.  Their  location  subjects  the  filling  to  ex- 
treme crushing  strain  which  porcelain  will  not  stand.  The 
occlusal  surfaces  are  of  an  irregular  shape  and  made  up  of  a 
great  variety  of  forms  with  surfaces  in  any  number  of  planes. 
This  makes  the  right  angle  cavo-surface  angle  demanded  in 
porcelain  filling  improbable  and  results  in  exposing  porcelain 
margins  of  an  acute  angle. 

Cavities  in  Proximal  of  Incisors  and  Cuspids  not  Involving 
the  Angle.  Class  III.  This  class  of  cavity  is  ideal  for  por- 
celain inlays  and  is  by  far  the  most  sightly  filling  when 
properly   executed. 

These  Cavities  Should  be  Divided  into  three  classes  in  ac- 
cordance with  the  three  different  lines  of  approach. 

First  division.  Labial  approach.  Second  division.  Lin- 
gual approach.     Third  division.     Proximal  approach. 

Labial  Approach.  This  approach  should  be  decided  upon 
when  any  considerable  amount  of  the  labial  enamel  is  to  be 
replaced  and  a  lingual  wall  is  possible.     (Figure  45.) 

The  Gingival  Wall  should  be  extended  gingivally  to  in- 
clude all  affected  enamel.  It  should  be  flat  axio-proximally 
and  meet  the  axial  wall  at  an  angle  slightly  acute.  It  should 
meet  the  lingual  wall  at  an  angle  slightly  obtuse. 

The  Axial  Wall  should  be  flat  labo-lingually  and  be  con- 
tinuous  from   the   axio-lingual   line   angle  to  the   labial   cavo- 


248 


ESSENTIALS  OF  OPERATIVE  DENTISTRY 


surface  angle  which  results  in  the  entire  removal  of  the  labial 
wall.  This  wall  should  meet  the  lingual  and  incisal  walls  at 
an  acute  angle.  The  incisal  lingual  line  angle  should  be 
slightly  obtuse.  This  results  in  a  cavity  retentive  in  all  di- 
rections except  to  the  labial  which  gives  it  "draw"  in  this 
direction. 


Figure  45. 


Figure  46. 


Figure  47. 


Lingual  Approach.  The  whole  general  plan  is  reversed 
resulting  in  the  retention  of  all  or  a  good  portion  of  the 
labial  wall  and  an  entire  absence  of  the  lingual  wall  resulting 
in  the  draw  being  to  the  lingual.     (Figure  46.) 

To  Resist  the  Tipping  Strain  the  lingual  step  may  be  added. 
This  is  done  by  cutting  away  a  sufficient  amount  of  the  lin- 
gual enamel  resulting  in  two  axial  walls.  One  facing  the 
proximal  and  the  other  the  lingual.  This  creates  a  line  angle 
where  the  two  walls  unite,  the  axio-axial  line  angle  which 
should  be  a  rounded  angle.  Just  before  setting  the  inlay  the 
axial  wall  should  be  slightly  grooved  next  to  the  surrounding 
walls,  except  in  the  region  of  the  incisal  point  angle. 

Proximal  Approach.  This  method  of  approach  should  be 
used  when  the  adjacent  tooth  is  temporarily  removed  or  there 
is  ample  space  due  to  irregularities  or  an  abundance  of  separa- 
tion has  been  obtained.     (Figure  47.) 

The  outline  should  be  that  of  a  generous  curve  and  the 
enamel  walls  should  present  a  flat  face  to  the  proximal.  The 
axial  wall  should  be  flat  or  convex  to  the  proximal  and  have 
all  surrounding  walls  meet  it  at  angles  slightly  obtuse.  This 
results  in  draw  directly  to  the  proximal. 

Cavities  in  Proximal  of  Incisors  and  Cuspids  Involving  the 
Angle.  Class  4.  Plan  one  Class  4.  This  plan  of  angle  re- 
storation may  be  successfully  accomplished  with  porcelain 
when  the  conditions  of  stress  would  permit  of  this  plan  being 


PREPARATION  OF  CAVITIES  249 

used  with  any  other  material.  The  cavity  form  Is  the  same 
as  that  just  described  for  a  class  three,  proximaf  approach, 
adding  the  ang-Ie.     (Figure  48). 

Proximal  Approach  May  be  Used  in  this  instance  under  the 
same  conditions.  In  addition  thereto  the  incisal  approach 
may  be  used  when  excess  separation  has  been  produced  a 
little  greater  than  the  length  of  the  incisal  line  angle,  as  well 
as  more  than  the  thickness  of  the  inlay  measuring  from  con- 
tact point  to  the  greatest  depth  of  the  axial  wall,  which  per- 
mits the  filling  entrance  from  the  incisal. 

To  Break  the  Cement  Line  on  the  Incisal  Edge  a  rounded 
groove  should  be  made  from  the  external  end  of  the  incisal 
line  angle  to  the  incisal  cavo-surface  angle. 

Plan  Two  Class  4,  is  not  suitable  for  porcelain  filling  as 
the  material  will  not  stand  the  strain  at  union  of  step  and 
cavity  proper. 

Plan  Three  Class  4.  The  addition  of  the  lingual  step  makes 
many  angle  restorations  with  porcelain  practical,  as  the  tip- 
ping strain  can  be  well  provided  for  by  grooving  in  the  lin- 
gual axial  wall  next  to  the  distal  or  mesial  wall  owing  to 
whether  the  cavity  is  distal  or  mesial.  The  cavity  should  be 
so  shaped  that  the  draw  is  directly  to  the  incisal.  The  gingi- 
val wall  should  be  flat  and  meet  both  axial  walls  at  an  acute 
angle.  The  axio-labial  line  angle  should  be  acute.  The 
lingual  axial  wall  should  be  concave.  The  axio-axial  line 
angle  should  be  a  rounded  angle  and  continue  out  to  the  in- 
cisal cavo-surface  angle.     (C  figure  34.) 

Plan  Four  Class  4.  In  angle  restoration  the  creation  of 
both  incisal  and  lingual  steps  is  most  popular.  The  incisal 
step  is  formed  in  much  the  same  way  as  when  gold  is  to  be 
used.  However  the  pulpal  wall  should  be  placed  farther 
from  the  incisal  edge  and  be  laid  in  a  plan  less  acute  to  the 
axial  wall  than  for  gold. 

The  angle  formed  by  the  junction  of  these  walls,  the  axio- 
pulpa!  angle  should  be  rounded.  In  forming  the  lingual  step 
the  enamel  may  be  removed  entirely  to  a  level  of  the  gingival 
wall,  or  it  may  be  only  as  much  of  the  incisal  portion  as  may 


250  ESSENTIALS  OF  OPERATIVE  DENTISTRY 

seem   necessary   to  strengthen  the  body  of  porceiain   in  the 
incisal  region  and  resist  the  tipping  strain.     (D  Figure  34). 


Figure  48.  Figure  49.  Figure  50. 

The  Treble  Step  as  Shown  in  Figure  49  is  of  service  in 
cases  where  there  has  been  extensive  loss  of  tooth  structure 
particularly  in  devital  cases.  This  plan  results  In  a  gingival 
wall  and  two  pulpal  walls.  Also  in  three  short  axial  walls 
placed  on  an  equal  number  of  levels.  The  gingival  and  pul- 
pal walls  should  be  made  to  meet  the  axial  walls  at  acute 
angles.  Each  of  the  two  pulpal  walls  should  be  grooved 
from  the  connecting  axial  walls,  and  each  axial  wall  in  the 
central  portion  resulting  in  a  continuous  groove  from  gingio- 
axial  line  angle  to  the  incisal  edge.  This  cavity  has  draw 
directly  to  the  incisal. 

Cavities  Occurring  in  the  Gingival  Third  Class  5.  Labial 
cavities  in  the  gingival  third  are  favorite  places  for  porcelain 
and  should  to  a  large  measure  displace  gold.  If  the  cavity 
extends  beneath  the  gum  line,  the  gum  should  be  forced  from 
position  by  previous  packing  of  gutta-percha  or  cotton  satur- 
ated with  chlora-percha. 

Outline  Form  should  be  the  same  as  for  other  filling.  The 
axial  wall  should  be  the  miniature  of  the  tooth  surface  where 
in  the  cavity  occurs.  The  gingival  wall  should  be  flat  and 
meet  the  axial  at  an  acute  angle.  All  other  surrounding  walls 
should  meet  the  axial  at  slightly  obtuse  angles.  This  gives 
a  cavity  with  draw  to  the  labial  the  incisal  portion  swing  out 
in  advance,  the  inlay  going  to  place  gingival  first. 

This  hinge  movement  is  sHght  but  constitutes  a  valuable 
point  in  subsequent  retention.  Just  before  setting  the  inlay 
the  axio-incisal  line  angle  should  be  sharpened  to  add  reten- 
tion form.     (Figure  50.)     In  cases  where  the  decay  resulting 


PREPARATION  OF  CAVITIES  251 

in  a  cavity  materially  horseshoe  in  form  the  cavity  may  be 
filled  by  two  distinct  operations. 

This  is  accomplished  by  filling  the  cavity  with  cement  and 
cutting  out  one-half  and  filling  with  porcelain.  This  com- 
pleted, cut  the  other  half  out  and  proceed  to  fill  that  portion. 
This  results  in  two  porcelain  fillings  with  cement  between. 

One  Point  However  Must  be  Observed.  The  first  portion 
of  porcelain  will  necessarily  slightly  overlap  a  cement  wall. 
Before  setting,  this  portion  of  the  inlay  must  be  ground  at 
the  expense  of  the  external  surface  of  the  filling  to  reverse 
the  draw,  or  this  portion  of  the  remaining  cavity  will  be 
found  with  an  objectionable  under-cut  hard  to  manage. 

Restoration  of  a  Portion  of  the  Incisal  Edge.  The  general 
outline  in  this  class  of  cavities  when  they  are  simply  a  notch 
in  the  body  of  the  tooth,  is  that  of  the  half  moon  when  viewed 
either  from  the  labial  or  the  lingual.  However  the  lingual 
enamel  should  be  removed  for  a  greater  distance  root-wise 
resulting  in  a  lingual  step  to  provide  against  the  tipping 
strain.  The  pulpal  wall  should  have  a  groove  'mesio-distally 
in  its  central  portion  and  extend  well  up  along  both  mesial 
and  distal  walls,  and  with  the  larger  cavities  coming  out  to 
the  cavo-surface  angle. 

Restoration  of  the  Entire  Incisal  Edge.  Outline  Form. 
The  enamel  is  chiseled  root-wise  till  it  is  firm  and  will  result 
in  a  thickness  of  porcelain  at  all  points  equal  to  at  least  two 
millimeters. 

Retention  is  accomplished  by  the  addition  of  pfns,  or  a 
generous  lingual  step,  or  both.     (Figure  51). 

Jn  vital  cases  where  pin  retention  is  to  be  used  there  should 
he  cut  a  V  shaped  groove  mesio-distally  the  spreading  angles 
of  which  should  come  just  short  of  the  dento  enamel  junction 
labi^ly  and  lingually.  Mesially  and  distally  It  should  con- 
tinue to  the  cavo-surface  angle.  A  pin  hole  should  then  be 
bored  in  the  extreme  ends  of  this  groove  not  a  great  distance 
from  the  dento  enamel  junction  in  the  dentine  to  receive  the 
pins.  When  the  lingual  step  is  to  be  added  the  enamel  on 
the  lingual  is  removed  additionally  to  a  distance  root-wise  at 
least  equal  to  the  labial  exposure.     Also  an  amount  of  den- 


252 


ESSENTIALS  OF  OPERATIVE  DENTISTRY 


tine  sufficient  to  make  the  newly  created  axial  wall  meet  the 
two  pulpal  walls  at  right  angles.  If  pins  are  to  be  added  the 
holes  should  be  bored  in  the  floor  of  the  pulpal  wall  nearer 
the  labial  surface.  - 


Figure  51. 


Figure  52. 


In  Pulpless  Six  Anterior  teeth  the  pulp  chamber  may  be 
rounded  out  and  porcelain  so  baked  as  to  form  a  post  of  por- 
celain for  retention. 

Pulpless  Molars  are  treated  in  the  same  way. 

Treatment  of  Teeth  with  Mal-formed  Enamel,  The  major 
portion  or  all  of  the  enamel  can  be  successfully  replaced  with 
porcelain.      (Figure  52). 

The  enamel  is  removed  to  the  desired  point  resulting  in  a 
gingival  wall  entirely  encircling  the  tooth.  Sufficient  dentine 
is  removed  in  the  incisal  region  to  render  the  largest  girth 
at  the  gingio-axial  line  angle  which  is  continuous  around  the 
tooth.  This  leaves  a  peg  shaped  body  of  dentine  over  which 
the  porcelain  is  telescoped.  The  method  is  termed  the  jacket 
crown  and  the  method  of  construction  and  setting  is  fully 
described  in  the  writings  of  others  on  crown  work. 


CONSTRUCTION  AND  PLACING  OF  A  PORCELAIN  INLAY     253 


CHAPTER  XLIII. 

The  Construction   and  Placing  of   a   Porcelain  Inlay. 

Following  the  completion  of  cavity  preparation  the  next 
step  in  porcelain  inlay  filling  is  the  formation  of  a  matrix. 

A  Matrix  is  a  thin  piece  of  metal  shaped  to  the  cavity  form 
in  which  the  porcelain  is  fused. 

Matrix  Material  The  matrix  materials  in  common  use 
are  pure  gold,  pure  platinum  and  platinized  gold.  Fure  gold 
and  platinized  gold  can  be  used  only  with  what  is  termed 
low  fusing  bodies,  while  pure  platinum  can  be  used  with 
either  high  or  low  fusing  bodies.  Gold  is  more  easily  shaped 
to  cavity  form.,  but  tears  more  easily  and  does  not  hold  its 
shape  as  well  after  burnishing. 

Thickness  of  Foil.  The  most  popular  thickness  of  foil  to 
be  used  in  the  construction  of  a  matrix  is  1-1000  of  an  incH. 
Thicker  than  this  is  difficult  to  manipulate,  while  the  thinner 
foils  tear  too  easily,  and  are  more  liable  to  distortfon  during 
the  processes  of  building  and  fusing. 

Annealing  of  Matrix  Material.  This  is  best  accomplished 
by  placing  the  entire  sheet  of  material  as  it  comes  from  the 
supply  house  in  the  electric  oven  and  bringing  it  to  the  de- 
sired temperature  before  cutting  off  the  piece  desired  for  the 
case  in  hand.  Pure  gold  and  platinized  gold  should  be  brought 
to  the  full  red  heat  or  about  1200  or  1300  degrees,  Fr.  Platin- 
um should  be  carried  up  as  high  as  it  is  expected  to  carry 
the  temperature  during  the  process  of  fusing  and  held  there 
for  two  or  three  minutes.  It  is  not  necessary  to  anneal  sev- 
eral times  during  the  process  of  shaping  the  matrix. 

Methods  of  Forming  the  Matrix,  There  are  three  general 
methods  in  use  for  the  con.struction  of  a  matrix:  First,  burn- 
ishing directly  into  the  cavity.     Second,  Swaging  over  art  im- 


254  ESSENTIALS  OF  OPERATIVE  DENTISTRY 

pression  of  the  cavity.     Third,  Swaging  into  a  model  of  the 
cavity. 

Each  has  its  advantage  in  different  cases  and  are  recom- 
mended by  all  porcelain  workers.  However  the  combina- 
tion of  the  first  and  second  methods  will  bring  good  results 
and  is  the  method  requiring  the  least  time. 

Technic  of  the  Combination  Method.  First  take  an  im- 
pression of  the  cavity.  If  the  cavity  is  large  it  is  best  to  use 
modeling  compound,  trim  off  that  part  which  flares  out  over 
the  external  surface  of  the  tooth.  The  matrix  is  then  shaped 
over  this  impression  with  the  fingers  using  the  soft  part  of 
the  ball  of  the  thumb  as  a  counter  die. 

The  most  prominent  parts  of  the  impression  will  represent 
the  deepest  portion  of  the  cavity  and  will  assist  in  causing 
the  matrix  to  reach  this  without  tearing  which  is  accomplished 
by  using  the  impression  to  crowd  the  matrix  to  position. 
The  impression  should  be  removed  leaving  the  matrix,  which 
has  been  by  this  means  partially  swaged,  in  the  cavity. 

The  Removal  of  the  Impression  without  carrying  away  the 
matrix  is  accomplished  by  bending  the  portions  of  matrix 
exposed  above  the  cavo-surface  angle  away  from  the  impres- 
sion. The  matrix  should  not  be  burnished  down  onto  the 
external  surface  of  the  tooth  till  the  other  portion  has  been 
thoroughly  conformed  to  the  cavity  walls. 

When  the  impression  has  been  removed  the  matrix  should 
be  thoroughly  burnished  to  all  cavity  walls  beginning  at  the 
seat  of  the  cavity  first.  This  burnishing  is  done  with  suitable 
smoothfaced  instruments,  keeping  moistened  chamois  skin 
discs,  between  the  instrument  and  the  matrix. 

The  cavity  should  now  be  packed  with  damp  cotton  balls 
crowding  the  matrix  ahead  of  them  to  every  part  of  the  cavity. 
While  this  cotton  is  in  position,  the  matrix  should  receive 
thorough  burnishing  at  the  cavity  margins  and  finally  be 
turned  out  on  to  the  external  surface  of  the  tooth  a  distance 
of  one-fourth  of  a  millimeter  to  one  full  millimeter  in  all  lo- 
cations except  one,  which  may  be  two  or  three  millimeters. 

This  one  place  will  facilitate  handling  during  the  process  of 


•      CONSTRUCTION  AND  PLACING  OF  A  PORCELAIN  INLAY     255 

filling  in  the  porcelain.  The  cotton  may  now  be  removed  and 
gum  camphor  or  gold  inlay  casting  wax  crowded  into  the 
cavity  over  the  matrix  filling  the  cavity  nearly  full  with  one 
piece  of  material  packed  to  place  with  a  flat-faced  amalgam 
burnisher  as  large  as  the  cavity  will  admit. 

Removal  of  Matrix.  The  matrix  is  then  removed  from  the 
cavity  by  sticking  the  tine  of  an  explorer  into  the  body  of  the 
camphor  or  wax  near  its  central  portion.  The  matrix  and 
wax  or  camphor  still  on  the  tine  of  the  explorer  should  be 
immersed  in  alcohol  if  camphor  has  been  used  or  chloroform 
if  wax  has  been  used,  which  will  immediately  loosen  the  tine 
and  dissolve  the  material  from  the  matrix  when  the  matrix 
should  be  picked  up  in  the  lock  tweezers  at  that  portion  where 
the  metal  has  been  left  to  extend  the  farthest  from  the  cavo- 
surface  angle. 

The  matrix  should  now  be  passed  through  the  alcohol  flame 
when  the  camphor  or  wax  remaining  will  be  burned  off  leav- 
ing no  ash. 

Wood  as  an  Impression.  In  simple  small  cavities  it  is  well 
to  shape  a  piece  of  soft  pine,  (as  cork  pine),  to  proximately 
fit  the  cavity.  This  should  be  then  introduced  against  the 
deepest  portion  of  the  cavity  and  given  a  few  blows  from  the 
mallet  which  will  cause  the  wood  to  conform  to  the  floor  of 
the  cavity.  This  should  then  be  used  as  an  impression  and 
the  matrix  forming  proceded  with,  as  described  when  model- 
ing compound  has  been  used.  The  use  of  the  stick  with 
modeling  compound  on  the  end  is  of  advantage  in  large  deep 
cavities  where  the  pulp  chamber  is  to  be  filled  with  porcelain  in 
place  of  metal  pin.  By  this  means  it  is  possible  to  place  a 
matrix  well  to  the  bottom  of  any  cavity  without  tearing,  pro- 
vided the  walls  are  regular  and  have  the  proper  draw  devoid  of 
under  cuts. 

Taking  the  Spring  Out  of  a  Matrix.  If  a  matrix  seems  to 
retain  "spring"  and  does  not  seem  to  lay  well  on  all  surfaces, 
as  frequently  met  with  in  complex  cavity  outlines,  this  may 
be  removed  by  the  following  method : 

When  cavity  is  thoroughly  packed  with  wet  cotton,  stretch 


256  ESSENTIALS  OF  OPERATIVE  DENTISTRY 


a  piece  of  rubber  dam  over  the  matrix,  cotton  and  all,  and 
thoroughly  burnish  the  entire  outline.  If  "spring"  still  per- 
sf^is',  remove  matrix  and  anneal  and  repeat  method,  v^hen  it 
wiM  be  found  that  the  fault  has  been  removed. 

Selection  of  Porcelain.     The  selection  of  that  portion  of  the 

inlay  which  replaces  dentine  and  that  which  replaces  enamel 
should  be  attended  to  before  the  process  of  building  begins. 
The  part  replacing  dentine  should  be  of  foundation  body 
coarsely  ground  and  of  a  yellow  color  in  all  vital  cases.  In 
deyital  cases  this  shade  may  be  darkened  by  the  addition  of 
the  brown  shade,  and  in  vital  teeth  for  young  patients,  par- 
ticularly if  the  cavity  is  shallow,  or  on  a  distal  surface,  the 
addition  of  white  powder  is  of  advantage  to  lighten  the  shade 
of  yellow. 

The  enamel  shades  may  be  decided  upon  after  a  careful 
study,  of  the  shades  and  hues  found  in  each  case.  Delicate 
shading  is  secured  by  building  one  layer  upon  another  get- 
ting the  benefits  of  reflected  light.  The  deep  and  pronounced 
shades  and  colors  are  best  obtained  by  building  in  sections. 
Teeth  that  are  much  of  one  color  and  not  pronounced  in  lines 
of  shades  will  be  best  represented  by  the  layer  method  while 
teeth  that  are  decidedly  yellow  at  the  cervix  and  pronouncedly 
blue  at  the  incisal  edge,  are  best  represented  by  building  in 
sections  provided;  the  cavity  involves  both  regions  spoken  of 
as  in  Class  4,  (proximo-incisal.) 

After  the  different  sections  have  been  appHed  and  brought 
to  a  hard  biscuit  fuse,  a  uniform  layer  of  neutral  color  is  ap- 
plied over  the  whole  and  all  fully  fused. 

Applying  the  Porcelain  to  the  Matrix.  The  foundation 
body  is  put  upon  the  porcelain  or  glass  slab  and  sufficient 
distilled  water,  or  alcohol  or  a  mixture  of  both,  added  to  make 
a  stiff  paste,  stiff  enough  to  retain  its  shape  when  taken  up 
on  the  point  of  a  spatula. 

A  small  quantity  of  this  is  laid  in  the  bottom  of  the  matrix 
arid  by  a  little  jolting  made  to  flow  over  the  surface.  This 
jolting  is  best  produced  by  drawing  the  edge  of  a  fine  gold 
file  over  the  tweezers  holding  the  matrix.  The  additions 
should  bd  continued  till  sufficient  body  has  been  added.     Ex- 


CONSTRUCTION  AND  PLACING  OF  A  PORCELAIN  INLAY     257 

cess  moisture  is  removed  by  repeated  jolting  and  absorbing 
with  blotting  paper.  Use  dark  colored  blotting  paper  so  as 
to  detect  any  paper  fibres  which  by  accident  adhere,  which 
should  be  removed.  The  addition  of  dry  porcelain  of  the 
same  color  will  take  up  the  excess  moisture,  the  surplus  ad- 
hermg  powder  bemg  brushed  off  with  a  small  brush 

In  Case  the  Matrix  is  Torn,  the  opening  has  to  be  compara- 

ItVTsV'  ''""  ''^  ^°"^^^^"  ^°  ^""  ^^-"^h-  -'ess 
matrix  is  damp  on  cavity  side  or  too  moist  a  mix  is  beine 

apphed.  Should  any  of  the  porcelain  flow  through,  it  can  be 
::rr:d  ;lVdr^  "-"  --^^^  ^^^  porcela1n>asr: 

Do  not  apply  a  wet  brush  to  cavity  side  of  matrix.     The 

nlay  should  now  be  placed  in  the  oven  and  fused  sufficiency 

to  produce  the  greater  part  of  the  shrinkage,  but  not  to  a  fuH 

gloss.     When  removed  from  the  oven  if  more  foundation "s 

needed  ,t  should  be  added  and  fired  to  a  high  biscuit. 

The  Enamel  in  Proper  Shades  is  now  added,  either  in  lav 
ers  or  sections,  and  again  fired  to  a  high  biscuit.  Th  iX' 
shouM  then  be  tried  into  the  cavity  for  bulk  and  contour  H 
not  correct  more  enamel  is  added.  When  the  contour  suits 
he  mlay  .s  replaced  in  the  oven  and  fired  to  a  full  glaze.  The 
skill  necessary  to  reproduce  the  colors  of  the  teeth  comes  with 
practice  and  the  longer  one  engages  in  this  work  the  more 
often  will  the  results  please  the  operator. 

Technic  of  Fusing  Porcelain.     The  furnace  should  be  first 

heated  up  to  a  bright  red  and  held  there  for  a  minute  or  two 

o  thoroughly  warm  the  fire  clay  clear  through  and  then  The 

WZT^'I  '°  '^  ''''  '""°"'  ^°  "^^^"^-"  ^  ---oven 
When  ready  to  fuse,  shut  furnace  completely  off  provided 

the  oven  shows  any  redness.     Never  put  an   inlay  mix  into 

a  hot  oven,  as  it  causes  too  rapid  evaporation  of  the  moisture 

producing  checks  and  an  extremely  friable  porcelain 

When  inlay  is  in  position  in  the  oven,  put  lever  on  second 

or  third  button  and  advance  only  when  the  needle  of  the  milli- 

ammeter  ceases  to  advance.     The  heat  should  be   increased 

gradually  and   when  it  has  reached  the   desired   degree  im- 


258  ESSENTIAL.S  OF  OPERATIVE  DENTISTRY 

mediately  shut  off.     Each  furnace  has  a  way  peculiar  to  itself 
and  each  operator  should  learn  the  time  for  perfect  results. 

Grinding  to  Contour.  After  the  final  fusing  the  inlay 
should  be  tried  in  and  ground  to  contour  and  articulation 
on  the  incisal  or  occlusal  surface  before  removing  the  matrix. 

To  remove  the  Matrix.  Drop  inlay  and  matrix  in  alcohol 
or  water,  then  remove  and  peel  the  matrix  from  the  inlay, 
drawing  from  the  margins  all  around  first,  then  from  the  body 
of  the  filling.  This  procedure  prevents  chipping  at  the 
margins. 

Etching  the  Cavity  Side  of  Inlay.  When  matrix  has  been 
removed  the  inlay  should  be  embedded,  contour  surface  down, 
into  a  sheet  of  pink  base  plate  wax.  With  a  warm  spatula 
seal  entirely  around,  being  sure  to  cover  the  edges  of  the  in- 
lay on  cavity  side  for  a  short  distance,  say  one-half  milli- 
meter. This  leaves  the  cavity  side  exposed,  upon  which  is 
applied  hydrofluoric  acid.  This  is  applied  by  dipping  a  stick 
in  the  wax  bottle  in  which  the  acid  is  delivered,  and  painting 
the  inlay  with  a  small  quantity  of  the  acid.  Two  minutes  will 
generally  be  sufficient  to  thoroughly  etch  the  surface. 

Toilet  of  Inlay.  The  inlay  should  be  flooded  with  water, 
removed  from  the  wax  and  placed  in  boiling  water  for  a  few 
minutes  and  then  given  a  chloroform  bath,  and  dried  with 
warm  air  while  laying  on  spunk  or  blotting  paper,  and  should 
not  be  again  contacted  with  the  hands  on  the  cavity  side. 

Toilet  of  Cavity.  The  cavity  should  be  rendered  dry.  All 
inlays,  and  particularly  the  large  ones,  are  best  set  with  white 
cement  with  the  faintest  tinge  of  cream.  The  attempt  to 
match  the  color  of  tooth  substance  with  the  cement  is  an  error 
as  the  pigment  in  the  cement  increases  the  shadow  line  which 
is  objectionable.  Use  a  white  cement  mixed  to  the  con- 
sistency of  greatest  adhesiveness  yet  thin  enough  to  flow  from 
between  inlay  and  cavity  walls  with  light  pressure.  This  will 
be  about  the  consistency  of  thin  cream.  The  cement  should 
be  thoroughly  and  rapidly  spatulated  and  when  the  "stick"  is 
felt  under  the  spatula  it  should  be  appHed  to  the  cavity  and 
the  surface  of  the  inlay  which  is  immediately  placed.     Use 


CONSTRUCTION  AND  PLACING  OF  A  PORCELAIN  INLAY     259 

a  non-corrosive  spatula,  preferably  bone  or  agate.  Apply  to 
cavity  with  a  flattened  orangewood  stick.  Press  inlay  to  po- 
sition with  a  stick  of  orangewood  using  gentle  pressure,  gent- 
ly tap  the  end  of  stick  with  the  knuckle  of  the  forefinger,  or 
blows  of  equally  cushioned  nature. 

In  labial  and  buccal  fillings,  class  5,  the  inlay  should  re- 
ceive gentle  pressure  for  five  or  ten  minutes.  In  proximal 
classes  3  and  4  the  filling  should  be  gently  wedged  against 
the  proximating  tooth  or  tightly  ligatured  to  position  and  so 
left  for  some  hours. 

The  Finishing  should  be  left  till  another  sitting.  If  the 
building  has  been  well  done  there  will  be  little  to  do.  All 
overhanging  margins  should  be  dressed  down  with  fine  stones 
and  disks  and  the  surface  polished  with  small  Arkansas 
stones,  using  a  light  hand  and  keeping  the  stones  well 
watered. 


260  ESSENTIALS  OP  OPERATIVE  DENTISTRY 


CHAPTER  XLIV 

Management    of    Children's   Teeth. 

The  management  of  children's  teeth  presents  two  diffi- 
culties additional  to  the  management  of  the  teeth  of  adults. 

The  first  difficulty  and  many  times  the  most  important  is  the 
management  of  the  child.  Children  are  very  susceptible  to 
external  influence  and  even  when  quite  young  believe,  all 
they  hear.  The  conversation  of  the  older  ones  about  the 
home  pertaining  to  the  "horrors"  of  the  dental  office,  has 
many  times  so  poisoned  the  mind  of  the  child  that  it  prejudges 
the  dentist  and  his  efforts  to  the  extent  of  preferring  any  other 
punishment  rather  than  meet  the  dentist,  even  for  an  ex- 
amination. 

The  First  Visit  of  a  child  should  be  made  one,  wherein 
there  is  an  entire  absence  of  pain,  or  even  inconvenience  on 
the  part  of  the  child. 

Such  visits  should  be  repeated  till  absolute  confidence  has 
been  secured.  After  this  has  been  thoroughly  established, 
the  children  of  a  clientele  will  prove  as  easily  managed  as 
the  adults,  and  in  after  years  are  the  most  tenacious  patrons, 
seldom  changing  their  dentist  through  life. 

The  Second  Difficulty  with  the  management  of  deciduous 
teeth  is  the  comparatively  short  life  of  the  most  careful  opera- 
tions. The  teeth  are  themselves  but  temporary.  All  about 
them  is  a  panorama  of  change  and  we  can  hope  at  best  for 
only  temporary  results.  Parents  should  be  given  to  under- 
stand this  feature  of  the  services  and  not  be  led  to  misjudge 
the  skill  of  an  operator  by  the  results  of  operations  on  the 
teeth  of  children. 

Early  Attention  is  imperative  and  the  keynote  to  success. 
All  small  enamel  defects  should  be  sought  out  and  fillings 
made  as  soon  as  such  are  found  to  exist.  It  is  hopeless  to 
attempt  the  salvage  of  deciduous  teeth  after  the  pulps  have 


MANAGEMENT  OP  CHILDREN'S  TEETH  litil 

become   involved   and    subdental   disorders    have   been    estab- 
lished. 

Oral  Hygiene  With  Children  should  be  established  early. 
The  parents  should  receive  thorough  instructions  as  to  the 
use  of  the  toothbbrush,  with  or  without  a  dentrifice,  as  the  child 
prefers,  and  a  daily  attention  established  at  about  the  age 
the  full  complement  of  deciduous  teeth  are  insitu. 

Frequent  Visits  to  the  Dentist  are  essential ;  even  more 
than  with  adults,  as  the  destructive  process  runs  a  rapid 
course  when  once  established,  a  few  weeks'  neglect  often  re- 
sulting in  irreparable  injury.  These  visits  should  be  estab- 
lished at  regular  and  frequent  intervals,  as  the  most  un- 
hygienic conditions  may  result  from  only  a  few  days'  neglect 
and  upon  early  detection  and  eradication  depends  the  suc- 
cess of  interference. 

Length  of  Time  at  Each  Sitting  should  not  exceed  thirty 
minutes  for  a  child  under  twelve  years  of  age  and  should  not 
exceed  one  hour  till  after  18  years  of  age.  Great  care  should 
be  exercised  in  causing  the  child  any  considerable  amount  of 
pain.  Better  that  the  filling  consist  of  temporary  stopping 
to  last  but  a  few  days  than  to  cause  lasting  memories  of  den- 
tal pains  inflicted  by  the  dentist. 

The  Filling  Materials  to  be  Used,  are  limited  to  those  of 
speedy  manipulation,  and  those  requiring  a  minimum  of  con- 
venience form.  This  will  place  in  the  list,  amalgam,  tin, 
gutta-percha  and  cements. 

Cavity  Preparation  should  be  limited  to  the  removal  of  the 
major  portion  of  decay,  sterilization  and  securing  the  cleav- 
age of  the  enamel  in  cavity  outline  by  the  use  of  the  chisel. 
All  else  should  be  avoided. 

Extension  for  Prevention,  extension  for  resistance,  flat 
seats  for  fillings,  line  angles  and  point  angles  and  all  else  in 
cavity  preparation  so  carefully  applied  to  filling  the  teeth 
of  adults  shoulcl  be  ignored  when  dealing  with  deciduous 
teeth.  If  decay  has  not  left  the  cavity  naturally  retentive, 
cement  should  be  resorted  to  instead  of  ''utting'. 


262  ESSENTIALS  OF  OPERATIVE  DENTISTRY 

Cavities  Class  I.  Pit  and  fissure  should  be  filled  with 
amalgam  or  tin  under  as  dry  conditions  as  can  be  secured 
without  the  rubber  dam.  The  use  of  the  rubber  dam  should 
be  restricted  to  the  six  anterior  superior  teeth  and  when  used 
should  be  very  loosely  ligatured. 

Cavities  Class  II.  Proximal  in  molars  should  be  filled  with 
copper  amalgam.  When  the  retentive  form  is  not  good  in 
the  cavity  without  much  cutting,  the  amalgam  should  be  laid 
in  soft  cement  in  which  case  ordinary  amalgam  will  do  as 
well  or  better  than  copper  amalgam. 

When  Two  Cavities  Exist  in  molar  proximal  space  which 
are  not  retentive  it  is  good  practice  to  fill  the  two  cavities  as 
one,  counting  on  refilling  the  cavity  in  the  second  molar  if  the 
first  molar  is  lost  early,  or  perchance  when  this  has  failed, 
which  it  will  sooner  or  later,  the  cavities  will  return  with  in- 
dependent retentive  form. 

Cavities  Class  III.  should  be  filled  with  cement  with  rubber 
dam  in  position.  If  decay  has  progressed  till  angle  is  lost  or 
partially  so,  do  not  build  to  contour  but  fill  as  a  class  thr^e. 
Classes  4,  5,  6  should  be  ignored. 

Treatment  of  Exposed  Pulps  in  deciduous  teeth.  Pulp  de- 
vitalization with  deciduous  teeth  should  never  be  attempted. 
Pressure  anaesthesia  will  not  prove  successful.  Arsenic 
should  never  be  applied  to  deciduous  teeth.  The  risk  is  too 
great  and  is  condemned  in  every  case.  If  the  pulp  is  exposed 
and  aching,  clean  out  the  debris,  flood  with  warm  water  dry 
and  phenolize.  Apply  a  pledget  of  cotton  saturated  with  oil 
of  cloves  for  12  or  34  hours.  When  case  returns,  dry  and 
again  phenolize  and  apply  a  paste  of  phenolized  iodoform 
over  which  place  a  filling. 

If  the  pulp  has  begun  to  suppurate,  the  necrosed  tissue 
should  be  cut  away  and  the  space  filled  with  a  paste  made  of 
oil  of  cloves  and  the  oxide  of  zinc  powder,  over  which  place 
a  filling  of  temporary  stopping.  The  pulp  will  usually  die 
under  this  without  further  pain. 

When  case  returns,  which  should  be  in  about  two  or  three 
weeks,  the  canals  should  be  cleansed  and  filled  with  a  paste 


MANAGEMENT  OF  CHILDREN'S  TEETH  263 

made  from   campho-phenique  and  iodoform  and   cavity  filled 
with  a  plastic  filling. 

Treatment  of  Abscessed  Deciduous  Teeth.  Such  teeth 
should  be  allowed  or  assisted  to  point  externally,  as  they  will 
generally  have  progressed  almost  to  the  stage  of  pointing 
before  the  dentist  is  visited. 

As  soon  as  the  active  stage  has  subsided,  the  case  should 
be  given  the  above  treatment  for  putrescence  and  filled.  If 
abscess  persists,  as  will  occasionally  be  the  case  in  spite  of 
all  methods,  a  small  hole  should  be  bored  in  the  buccal  sur- 
face just  sub-gingivally  to  the  pulp  chamber,  leaving  the  fill- 
ing in  place. 

Inter-Proximal  Grinding  is  of  service  when  filling  is  out  of 
the  question.  This  is  practiced  much  after  the  same  method 
it  was  used  in  primitive  days  with  the  permanent  teeth. 

The  proximal  surfaces  are  cut  away  so  that  they  are  non- 
retentive  to  food  particles  and  the  sides  of  the  remaining  sur- 
faces thoroughly  exposed  to  the  excursions  of  food  in  masti- 
cation. With  anterior  teeth  the  contact  point  is  thereby 
moved  to  near  the  gingival  line.  With  posterior  teeth  the 
contact  point  is  removed  as  far  to  the  buccal  as  possible  by 
widening  the  lingual  embrasure  at  the  expense  of  both  proxi- 
mating  teeth.  This  method  is  unsightly  in  the  anterior  teeth 
and  not  altogether  without  its  objections  when  used  on  pos- 
terior teeth  but  it  is  nevertheless  good  practice  in  many  cases 
as  it  materially  retards  the  process  of  decay. 

The  Management  of  Permanent  Teeth  in  Childhood,  con- 
stitutes one  of  the  greatest  trials  of  dental  practice  and  is 
at  the  same  time  of  the  utmost  importance.  These  teeth  are 
erupted  at  a  time  of  life  when  the  oral  conditions  are  the 
most  favorable  to  decay.  Again  these  teeth  are  expected  to 
give  their  user  the  longest  period  of  service  of  any  of  the  en- 
tire set  of  permanent  teeth. 

It  requires  extra  vigilance  on  the  part  of  the  dentist  to  pre- 
vent irreparable  injury  to  the  first  permanent  molars,  as  the 
parents  are  not  usually  aware  that  permanent  teeth  are  pre- 
sent at  this  age   and  do  not  assist  the  dentist  in  detecting 


264  ESSENTIALS  OP  OPERATIVE  DENTISTRY 

incipient  decays.  More  is  expected  and  required  of  the  first 
permanent  molar  than  any  other  tooth.  It  must  stand  the 
onslaughter  of  the  most  unhygenic  conditions. 

It  must  give  its  possessor  longer  years  of  service  and  that 
in  a  position  in  the  mouth  most  often  subjected  to  the  stress 
of  mastication.  Slight  faults  in  enamel  should  be  sought  out 
early  and  filled  v^ith  amalgam  to  be  changed  for  gold  in  more 
mature  years.  When  badly  broken  down  they  should  be  re- 
stored to  full  contour  with  amalgam  and  crowned  only  when 
the  second  permanent  molar  is  fully  in  position.  If  gold  is 
used,  it  should  be  in  the  form  of  the  inlay  under  about  14 
years  of  age  as  the  tooth  should  not  receive  severe  and  pro- 
longed condensing  force  till  certain  of  full  development,  which 
is  from  10  to  14  years  with  the  first  permanent  molar. 

Treating  First  Permanent  Molars.  In  treating  and  filling 
the  root  canals  of  these  teeth  before  fully  developed,  the  apical 
foramen  will  many  times  be  found  quite  large.  In  some  cases 
the  circulation  is  so  great  that  devitalization  is  most  difficult. 
In  uncertain  cases  it  is  well  to  use  a  medicated  root  canal 
filling  that  is  easy  of  removal  and  instruct  patient  to  return 
in  a  few  months  or  perhaps  a  year  for  final  filling. 

A  good  root  filling  for  such  cases  is  phenolized  iodoform  for 
the  canals,  topped  with  gutta-percha  base  plate  for  the  pulp 
chamber  and  covered  with  amalgam.  When  case  returns  it 
will  generally  be  possible  to  determine  the  length  of  root  and 
size  of  foramen  when  a  correct  root  fillinsr  of  chlora-percha  will 
be  possible.  In  applying  arsenic  for  devitalization  in  teeth 
that  have  not  fully  developed  as  may  be  expected  from  their 
age,  great  care  should  be  exercised,  as  there  is  great  danger  of 
apical'  arsenical  poisoning  which  nearly  always  causes  the 
speedy  loss  of  the  tooth. 


CHAPTER    INDEX. 


A  chapter  index  only  is  given.     The  subjects  treated  of  in  each 

chapter  may  be  found  in  the  contents  which  is  given  in  the  fore  part 
of  this  book. 

Page 

Abraded  Surfaces  Incisal   and  Occlusal — Class   6,  Management  186 

Alleviation   of  Dental   Pains 67 

Amalgam,    Manipulation 231 

Cavity  Nomenclature 36 

Cavity  Preparation 43 

Cement— Use  of 229 

Children's   Teeth — Management   of 260 

Cohesive   Gold — Manipulation 204 

Cohesive  Gold — Manipulation,  by  classes 211 

Combination  fillings 238 

Convenience    Form 57 

Dental    Histology 24 

Examination  of  Mouth,  Looking  to  Dental   Services 63 

Extraction,  Permanent  Teeth 129 

Extraction,    Temporary    Teeth 140 

Finishing   Enamel    Walls 5S 

Gaining  Access  in  Cavity  Preparation 40 

Gingival  Third  Cavities — Class  5,  Management  of 183 

Gold    Fillings— Finishing   of 218 

Gold   Inlays — Cavity   Preparation 189 

Gold   Inlays — Making  and   Setting 195 

Gutta-Percha— Use    of 232 

Hypersensitive  Dentine,  Treatment  of 88 

Instrument   Nomenclature 32 

Large  Proximal  Cavities  Endangering  the  Pulp — Class  2 168 

Moisture — Exclusion    of 78 

Outline  Form 50 


266  ESSENTIALS  OF  OPERATIVE  DENTISTRY 

Pit  and  Fissure  Cavities — Class  1,  Management  of 147 

Pit  and  Fissure   Cavities — ^Class   1,  Management  of   concluded  151 

Porcelain  Inlays — Cavity  Preparation 245 

Porcelain  Inlays — ^Construction  of 253 

Porcelain — Uses  of 241 

Prophylactic  Treatment  of  the  Mouth 71 

Proximal  Cavities  in  Bicuspids  and  Molars — Class  2,  Manage- 
ment   15C 

Proximal   Cavities   in  Incisors  and  Cuspids  not  involving  the 

Angle 169 

Proximal   Cavities   in   Incisors   involving  the   Angle — Class   4, 

Management  of 176 

Pulp   Devitalization   and   Removal 107 

Putrescent  Root  Canals — Management , ■- 117 

Removal  of  remaining  Carious  Dentine 58 

Retention  Form 5o 

Resistance  Form 53 

Root  Canals— The   Filling  of 125 

Tin— Use    of 234 

Toilet  of  Cavity 5S 

Tooth    Nomenclature 17 

Vital   Pulp— Protection   of 99 


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